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Group Health Insurance
Group Health Insurance (GHI) offers standardized medical coverage to a group of people. Such plans may often include additional health benefits like vision and dental procedures, as well as pharmacy coverage.
GHI helps ensure that employees have access to essential medical services, promoting their overall well-being and financial security.
Additionally, it often includes benefits such as routine check-ups, preventive care and prescription coverage, making it an attractive option for employees.
What is Group Health Insurance?
Group Health Insurance is a comprehensive health coverage plan provided by an employer or organisation to its employees or members. This type of insurance pools a group of people together under one policy, offering healthcare benefits at a more affordable rate compared to individual health plans.
Group medical insurance covers a range of medical services, including doctor visits, hospital stays, surgeries and prescription medications. It may also include preventive care such as vaccinations, routine check-ups and screenings. By providing this coverage, employers help ensure their employees have access to necessary medical care.
One of the main advantages of Group Health Insurance is that it spreads the risk across many people, which typically results in lower premiums for everyone involved. For most group health insurance plans, employers either pay the entire or a portion of the premium, making it even more affordable for employees.
Group Health Insurance not only offers financial protection to employees against high medical costs but also creates a healthier, more productive workforce for the employer.
Types of Groups Covered
According to IRDAI, a group, under a group health insurance policy, is defined as members coming together to engage in a common economic activity but not merely formed to obtain health insurance coverage benefits.
There are majorly two types of group insurance policy bearers:
Non-Employer-Employee Groups
These groups include members of registered welfare associations, credit cardholders of specific companies or banks and customers businesses offering insurance as an added benefit.
Employer-Employee Groups
These groups consist of employees from any registered organisations.
The organisations opting for Group Health Insurance coverage should have a Group Administrator or Proposer who will sign the proposal or the declaration form. They will be named in the Policy Schedule and may or may not be insured under the policy.
Tata AIG specialises in offering Group Health plans for both types of groups, ensuring comprehensive health coverage for all members.
Why Buy Group Health Insurance?
Employees are invaluable assets for any organisation. Their welfare and care are of utmost importance to the organisation. Changing lifestyles, rising medical costs & the recent pandemic have demonstrated to us how important it is to have insurance for employees.
The COVID-induced lockdowns had a great impact on the work of Small and Medium Enterprises (SMEs). To come to terms with the new reality and emerge from this downturn, SMEs have to find new ways to meet these challenges and pave the way for growth.
One way is to invest in the employees and their well-being through Group Health Insurance, which goes a long way in making sure that Employees appreciate the health and financial security provided through Insurance coverage now more than ever.
As more and more people nowadays look for work-life balance and a fair set of benefits from their organisation, hiring and retaining good employees is no longer an easy task. The importance of group insurance is aplenty and as an employer, a Group Health Insurance plan from Tata AIG can equip you to work towards employee wellness in several ways.
Better employee retention
Group health coverage from the employer gives employees and their families a sense of security. Moreover, it creates a feeling of belongingness, and employees feel cared for. This inclusiveness goes a long way in gaining the employees' loyalty, trust and sincerity.
Happier employees
The rising cost of medical treatment is often a cause of worry for many. Securing your employees with group health coverage frees them from the mental stress of unplanned medical expenses. Such plans help employees get free from the mental burden of high treatment costs and result in better mental health for them.
Motivated employees
Happy employees are motivated employees. The value and care your employees feel with Group Health Insurance boosts their motivation and contributes to a supportive and healthy workplace culture.
Advantages of Group Health Insurance Policy
Comprehensive Coverage
Employees covered under a group health insurance plan can enjoy comprehensive health coverage without a pre-medical examination. Depending on policy terms, this coverage can also extend to providing them with maternity coverage, regular doctor consultations, and much more. Moreover, unlike individual plans, where policyholders must undergo medical tests, group plans do not require any pre-purchase medical tests.
Covers Employees And Their Families
Group health insurance offers maximum employee benefits. Such a policy provides employees and their families with coverage against unforeseen and emergency medical expenses during hospitalisations. Depending on policy terms, the employee can choose to include some or all of their family members as dependents under their group plan.
Pre-Existing Disease Coverage from Day 1
Group health insurance offers financial security to the employees. These plans often allow coverage for pre-existing conditions from day one. This means that the organisation or employer can choose to include benefits for pre-existing diseases immediately, without waiting periods. This option ensures that employees receive necessary medical care right away, enhancing the overall value of the insurance plan.
Boosts Employee Morale
Group plans can help boost employee morale and increase a business's employee retention rate. People value jobs and work environments where they feel appreciated and cared for. As an added benefit, they can also help enhance employees' mental well-being and increase productivity, as employees are less likely to be burdened with any financial stress relating to their medical expenses.
More Affordable
Group plans are a far more affordable option when compared to other plans. This is because the insurer's risk is spread across a large number of employees, thereby lowering the overall cost of insurance on an individual basis.
Customisable
Group health coverage can be tailored by the employer to suit the group's specific size and needs. This customisation ensures that the coverage is relevant and beneficial for all members. Employers can adjust various aspects of the plan, such as the types of benefits offered and the coverage limits, to best meet their employees' requirements.
Who should buy Group Health Insurance?
Group Health Insurance is a valuable investment for various types of organisations, including young startups, small businesses, growing startups, medium-sized companies, established startups and large organisations.
Here is why each of these entities should consider purchasing group health insurance:
Young startups and growing startups
Providing health benefits with group health insurance can help attract and retain talented employees. In the competitive startup environment, offering healthcare coverage can set you apart from other employers. It shows that you care about your employees' well-being and are committed to employee security.
Small Businesses
Offering group health insurance can be a crucial factor in building a loyal and motivated workforce for a small business. Health insurance benefits can make your business more appealing to potential hires, helping you attract skilled employees. Additionally, group health insurance can improve employee satisfaction and reduce turnover, which is essential for a small business's stability and growth.
Medium Businesses
As your company grows, so do your employees' needs. Group health insurance can provide comprehensive employee protection with healthcare benefits that meet these needs. It can also enhance your company's reputation as a caring and responsible employer, making it easier to recruit and retain top talent.
Established Startups
For startups that have moved beyond the initial stages and are more established, offering corporate health insurance is a sign of maturity and stability. It demonstrates that the company is well-positioned to provide long-term benefits to its employees, which can boost the business’s brand image in the industry and among prospective employees.
Large Organisations
For large organisations, group health insurance is almost a necessity and serves as a means of cost control. With a large number of employees, offering comprehensive health coverage is essential to maintaining a healthy and productive workforce. It also helps manage healthcare costs more effectively through negotiated rates and better coverage options.
Benefits of Group Health Insurance for Employers
Group Health Insurance offers numerous benefits for employers, making it an essential consideration for any business looking to support its workforce and reduce costs.
Here are some key advantages:
Tax Benefits
One of the significant employer incentives for providing group health insurance is the tax advantage it offers. Employers can often deduct the cost of health insurance premiums as a business expense, lowering their overall tax burden. This makes offering health insurance a financially sound decision for employers who are looking for a means to promote employee care.
People-First Approach
By offering group health insurance, employers demonstrate a commitment to the well-being of their employees. This people-first approach can boost employee loyalty by showing that the company values its workforce. It creates a supportive work environment, which can lead to increased productivity and job satisfaction.
Lower Premiums
Group health insurance typically has lower premiums than individual plans. By pooling together a large number of employees, the risk is spread out, leading to more affordable rates. This cost-effective solution helps businesses manage their expenses while providing comprehensive health coverage.
Employee Value and Satisfaction
Providing health insurance is a competitive advantage in attracting and retaining talent. Employees value health benefits highly, and offering a robust health insurance plan can improve employee satisfaction and reduce turnover. A satisfied workforce is more likely to be engaged and committed to the company’s success.
Financial Well-Being
Group health insurance is a critical product for the financial well-being of the workforce. It protects employees from medical emergencies and provides peace of mind by ensuring they have access to necessary medical care. This financial security can lead to a more focused and less stressed workforce.
Customisable Policies
Employers can customise group health insurance policies to fit their budget and the specific needs of their employees. This flexibility allows businesses to choose the level of coverage that is most appropriate for their workforce, ensuring that they provide meaningful benefits without overstretching their financial resources.
Benefits of Group Health Insurance for Employees
Here are some of the most lucrative benefits of group health policies that the employees of an organisation can enjoy:
Timely Consultations
Employees can gain access to timely nutritionist and doctor consultations. This helps them manage their health more effectively. This also ensures that they can seek professional advice and support for their dietary and medical needs on time.
Booking Lab Tests
Employees can easily book lab tests, which are usually done at much-discounted rates. This benefit ensures regular monitoring of their health, leading to early detection and treatment of any potential diseases.
Ordering Medicines
Employees can now order discounted medicines hassle-free, as they can easily get prescriptions through the insurer’s network. This convenience saves time and ensures they receive their medications promptly.
Maternity Benefits with Zero Waiting Period
Many such plans offer maternity coverage with no waiting period. This ensures immediate financial support for expecting mothers and employees who are planning a family.
Employees Can Get Dependents Covered
Finally, such plans allow employees to get their dependents covered, providing comprehensive health benefits for their entire family.
Key Features of Group Health Insurance Policies
Since group insurance is a tailor-made health plan, these features are indicative and can differ based on customisation by the employer when deciding on their desired scope of coverage.
| Key Features | Details | |
|---|---|---|
Waiting Period | Option to Coverage from Day 1 | |
Policyholder | Employer | |
Insured Members | Employees only or Employees + Family Members as Dependents (Optional): Legal spouse, children, dependent parents | |
Mid-Term Addition of Dependents | New borns and spouses in case of marriage for a requisite premium. | |
In-Patient Treatment | Covered up to the Sum Insured and the Sub-Limit applicable per claim. | |
Pre-Hospitalisation Coverage and Post-Hospitalisation Coverage | Covered up to the number of days as specified in the policy schedule/ insurance certificate. | |
Day Care Procedures | Covered up to the number of days as specified in the policy schedule/ insurance certificate. | |
Domiciliary Treatment | Covered if opted for as per policy schedule | |
Maternity Cover | Covered if opted for as per policy schedule | |
Baby Day One Cover | Covered if opted for as per policy schedule | |
Pre/Post-Natal Cover | Covered if opted for as per policy schedule | |
Organ Transplant | Covered if opted for as per policy schedule | |
Cashless Treatment Claims | Available for Network Hospitals. | |
Ambulance Cover | Covered if opted for as per policy schedule | |
Network Hospitals | 11000+ hospitals across India. | |
Family Transportation Benefit | Covered if opted for as per policy schedule |
What is Covered in Group Health Insurance?
In-Patient Treatment
Indemnification of medical expenses incurred due to disease/ illness/ injury during the policy period that requires the insured person’s admission to a hospital as an in-patient for a minimum period of 24 consecutive hours. A daily hospital cash benefit is also available here.
Pre-Hospitalisation Expenses
Expenses for consultations, investigations, and medicines incurred up to the number of days as specified in the policy schedule prior to admission to the Hospital. The coverage can be claimed under In-patient Treatment/Day Care Procedures/Domiciliary Treatments.
Post-Hospitalisation Expenses
Expenses for consultations, investigations, and medicines incurred up to the number of days, as specified in the policy schedule, after discharge from the Hospital. Like pre-hospitalisation expenses, this benefit can be claimed under In-patient Treatment/Day Care Procedures/Domiciliary treatments.
Day Care Treatment
Coverage for expenses for listed Day Care treatment due to disease/ illness/ injury during the policy period taken at a hospital or a Day Care Centre. For more information, you can check our blog on common daycare procedures covered by health insurance.
Domiciliary Treatment
Coverage for expenses related to at-home or domiciliary treatments of the insured person if the treatment exceeds three days for management of an illness. It does not include coverage for enteral feedings or end-of-life care.
Note: Domiciliary hospitalisation means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:
- the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
- the patient takes treatment at home on account of non-availability of room in a hospital
Organ Transplant
Coverage for medical and surgical expenses of the organ donor for harvesting the organ where an insured person is the recipient. These expenses will be covered if the organ donation is in accordance and compliant with The Transplantation of Human Organs Act (Amended), 1994. The insured person must also have submitted an in-patient hospitalisation claim under the in-patient hospitalisation treatment cover to be eligible for this cover.
Ambulance Cover
Coverage for expenses incurred on transportation of the insured person in a registered ambulance to the hospital in the case of an emergency or transfer from one hospital to another for better treatment. The claim must be admissible under this policy's in-patient treatment or daycare procedures to be eligible for this cover.
Maternity Coverage
Coverage for maternity expenses for childbirth and/or maternity expenses like the medical and lawful termination of pregnancy and the medical resuscitation of the newborn baby as per the sub-limit specified in the policy schedule. In the case of ectopic pregnancies, while they aren't included under our maternity cover, they can still be claimed under the in-patient treatment clause of our Group MediCare policy.
Family Transportation Benefit
The transport cost of one immediate family member, like the insured person's legal spouse, child, parent, etc., is reimbursed if the insured person is admitted to a hospital at least 200 km away from their residence.
What is not Covered in Group Health Insurance?
Waiting Period
Any claim made during the policy waiting period, the waiting period for specific diseases and pre-existing diseases will not be covered. However, there are exclusions available for these.
Investigation and Evaluation
Expenses related only to primary diagnostics and evaluation purposes. Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment.
Rest and Respite Care
Expenses related to enforced bed rest and respite services for terminally ill people.
Obesity/Weight Control
Expenses related to the surgical treatment of obesity that does not fulfill all the below conditions:
- Surgery to be conducted is upon the advice of the Doctor.
- The surgery/procedure conducted should be supported by clinical protocols.
- The member has to be 18 years of age or older.
- Body Mass Index (BMI) of the patient is greater than or equal to 40 or greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
- Obesity - related cardiomyopathy
- Coronary heart disease
- Severe Sleep Apnea
- Uncontrolled Type2 Diabetes
Gender Change Treatment
Expenses related to treatment and surgery for gender change.
Cosmetic or Plastic Surgery
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following accidents, burns, or cancer or as part of medically necessary treatment. Additionally, this does not include dental treatments.
Addiction
Expenses for treatment for alcoholism, drug or substance abuse, or any addictive condition and their consequences.
Unproven Treatments
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment.
Miscellaneous
Expenses for some cases of refractive error treatment, injury due to adventure sports, breach of law, and sterility and infertility treatment.
Things to Consider When Comparing Group Health Insurance
When comparing group health insurance plans, it is essential to evaluate several key factors to ensure you select the best option for your organisation and employees.
Here are the main points to consider:
Value for Money
Ensure that the plan provides comprehensive coverage at a reasonable cost. Compare the premium costs, deductibles and out-of-pocket expenses to determine if the plan offers good value for the benefits provided. Look for a balance between affordability and the quality of coverage to ensure that both the employer and employees benefit.
Convenience
Consider the plan's convenience for both the employer and the employees. This includes the ease of managing the policy, the simplicity of enrolment processes and the availability of customer support. A plan that is easy to administer and understand will save time and reduce frustration for everyone involved.
Ease of Claims
The process for filing and settling claims should be straightforward and hassle-free. Look for insurers with the highest claim settlement ratio. Tata AIG has a user-friendly claims process that allows employees to submit claims easily and track their claim status. Quick and efficient claims processing is vital to ensure employees can access their benefits when needed.
Claim Settlement Ratio
The claim settlement ratio is an important metric that indicates the percentage of claims settled by the insurance provider. A higher ratio suggests that the insurer is reliable and efficient in processing claims. Choose a provider with a strong track record of settling claims promptly and fairly.
Nationwide Coverage
Ensure that the plan offers nationwide coverage, especially if your organisation has employees in different locations. A plan with a wide network of healthcare providers across the country ensures that employees can access medical services no matter where they are.
This is particularly important for businesses with remote workers or multiple office locations. Tata AIG has a pan-India presence. So, it does not matter where your company is located; we have got your back.
Additional Benefits
Look for plans that offer additional benefits beyond basic healthcare coverage. These can include wellness programs, preventive care services, telemedicine options and discounts on health-related products and services. Additional benefits can enhance the overall value of the plan and contribute to the well-being of your employees.
By carefully evaluating these factors, you can choose a group health insurance plan that meets your organisation's needs and provides valuable support to your employees.
Being an online insurance provider allows us to deliver group health insurance plans with extensive coverage at affordable rates. Plus, our online facilities allow you to compare multiple health policies on our site.
Eligibility Criteria to Purchase Group Health Insurance
- Tata AIG offers comprehensive group health insurance policies that cater to the needs of various groups. To purchase such a policy, certain eligibility criteria must be met. Understanding these criteria helps ensure that your group qualifies for the insurance and can take full advantage of the benefits offered.
- One of the primary group health insurance eligibility criteria is the size of the group. A minimum of seven members is mandatory to qualify for a group health insurance policy. This rule is set to ensure that the insurance pool is large enough to spread risk effectively, making it viable for the insurer and beneficial for the insured members.
- Consider a medium-sized tech company, "Tech Innovators Pvt. Ltd.," which employs 50 people. The company wants to ensure the well-being of its employees by providing health insurance. By meeting the eligibility criteria of having more than seven employees, Tech Innovators can purchase a group health insurance policy.
- This policy will cover all employees, providing them with access to essential healthcare services and additional benefits such as dental and vision coverage.
Why Choose Tata AIG Group Health Insurance Plan for Employees?
Tata AIG Group Health Insurance plans are one of a kind. Our online infrastructure allows us to streamline our services and be a one-stop solution for all your policy requirements.
Claims Settlement Ratio
A claims settlement ratio (CSR) can be an important factor when comparing group health plans, as it indicates the insurer's annual claim approval rate.
However, an insurer's CSR can decrease due to factors like fraudulent claims, claims against exclusions, or claims raised during waiting/grace periods. So, while CSR is an important factor, it should not be the sole deciding factor on purchase.
At Tata AIG, our CSR is 96.70%. We also offer online, paperless transaction services to help streamline your claims processes and claims tracking facilities to ensure transparency.
Geographical Presence
Having a wide range of network hospitals and clinics covered under your group health insurance plan ensures that all your employees have access to high-quality medical care no matter where they are. We have 11000+ network hospitals across India, where employees covered under our Group MediCare Policy can claim cashless facilities.
How to Apply for Group Health Insurance Policies?
Purchasing Group Health Insurance from Tata AIG is a straightforward process. Follow these steps to ensure you select and apply for the right plan for your organisation:
Assessment
Begin by assessing your group's healthcare needs. Consider the number of employees, their age, health conditions, and any specific requirements they might have. This initial assessment will help you determine the appropriate coverage amount and the type of plan that will best meet your organisation's needs.
Understanding these details is crucial for selecting a plan that provides comprehensive and adequate coverage for all employees.
Reach Out to Us
Contact Tata AIG to get started with your Group Health Insurance application. You can reach us via phone, email or through our website. Our representatives are available to guide you through the process, answer any questions you might have and provide expert advice on the available options.
They will help you understand the different plans and their benefits, ensuring that you make an informed decision.
Buy Online
For convenience, you can also purchase Group Health Insurance online. With us, you can explore the various plans available, compare their features, and select the one that best fits your organisation's needs. You can also opt for a personalised plan at your convenience.
Our online platform allows you to easily fill out the necessary forms and submit your application. Once your application is reviewed and approved, your policy will be activated.
How to Raise Cashless Claims for Group Health Insurance
Raising a cashless treatment claim for Group Health Insurance with Tata AIG involves a clear and detailed process.
Here is how you can go about it:
Intimation
- Emergency Hospitalisation: In the event of an emergency hospitalisation, you must inform Tata AIG within 24 hours of your admission to the hospital. This prompt intimation is crucial to initiate the cashless claim process.
- Planned Hospitalisation: For planned hospitalisations, inform Tata AIG at least 48 hours before the scheduled admission. This advance notice allows sufficient time to process the pre-authorisation request.
Cashless Claim Process
Request for Pre-Authorisation
- Visit the insurance/TPA desk at the hospital where you are admitted or planning to be admitted.
- Obtain the pre-authorisation form and complete it with all the required details. Ensure all information is accurate and complete to avoid delays.
- Please fax the completed pre-authorisation form to Tata AIG. The hospital’s insurance desk can assist you with this process.
Approval
- The claim management team at Tata AIG will review your pre-authorisation request.
- If the request meets the criteria and all information is in order, an approval letter will be sent to the hospital. This approval allows the hospital to proceed with the cashless treatment.
Query
- If the claim management team requires additional information or has any queries, they will raise a query.
- The hospital or the insured (you) must respond promptly to these queries. Providing timely and accurate information helps in the swift processing of your claim.
Rejected
- If the cashless claim is rejected for any reason, you can still go ahead with the treatment.
- In such cases, after receiving the treatment, you can file a reimbursement claim. Ensure you keep all the necessary documents, bills and receipts to support your reimbursement claim.
How to Raise Reimbursement Claims for Group Health Insurance
Raising a reimbursement claim for Group Health Insurance with Tata AIG is a straightforward process. Follow these steps to ensure your claim is processed efficiently:
Intimation
- Emergency Hospitalisation: Inform Tata AIG within 24 hours of your hospitalisation in case of an emergency. This timely notification is crucial to initiate the reimbursement claim process.
- Planned Hospitalisation: For planned hospitalisations, inform Tata AIG at least 48 hours before the scheduled admission. This advance intimation helps in processing your claim smoothly.
Reimbursement Claim Process
Claim Form Submission
- After discharge from the hospital, complete the reimbursement claim form accurately and provide all required details.
- Submit the completed claim form along with all necessary documents as per the policy terms and conditions. These documents typically include hospital bills, discharge summaries, prescriptions, diagnostic reports and any other relevant medical documents.
Approval
- The claim management team at Tata AIG will review your submitted claim form and documents.
- If everything is in order and meets the policy criteria, an approval letter will be sent to you confirming the acceptance of your claim.
Query
- If the claim management team requires additional information or has any queries regarding your claim, they will raise a query.
- You must respond promptly and accurately to these queries. Providing the required information quickly helps in the smooth processing of your claim.
Rejected
- If your reimbursement claim is rejected, Tata AIG will communicate the reason(s) for the rejection clearly.
- Understanding the reasons for rejection can help you address any issues or discrepancies for future claims.
Documents Required for Group Health Insurance Claim/Reimbursement
List of documents needed to avail cashless facility
- Insurance Card / Policy Copy
- Copy of Company photo ID.
- Customer Address Proof.
- Duly Filled CKYC Form if the Claimed amount is above ₹1 lakh
- Admission notes from a treating doctor.
- Previous OPD consultation papers with reports, if any.
- Previous discharge summary or any other medical records available with you.
- Any previously approved / settlement letter from Tata AIG for reference. (Optional)
List of documents needed to avail Reimbursement
- Duly filled and signed the Claim form
- Insurance Card or Policy Copy
- Medical Certificate signed by the doctor
- Original discharge summary & Original consolidated final bill.
- Break-ups required for the submitted final bill.
- Cash paid receipts of hospital/pharmacy/lab.
- Bank details of payee name with printed.
- Supportive investigation reports.
- In the case of implants used, invoices are required.
- In case of Accidental injuries, MLC/ FIR is required.
- In case of the death of the main member, please provide details of the nominee (as per policy schedule), along with the nominee's address and ID proof.
- In case the claim value is above ₹1 lakh, the CKYC form with mandatory columns filled, with a photograph of the main member and cross-signed on it.
What is a Health Card in a Group Health Plan?
A Health Card is a vital component of a Group Health Plan that serves as an identification and access card for individuals enrolled in the plan. It typically contains essential information about the member ID, policy period, age, date of birth and gender.
The primary purpose of a Health Card is to facilitate easy and efficient access to healthcare services within the network of providers associated with the insurance plan.
A Health Card typically includes information such as the policyholder's name, policy number, and other relevant identification details. It may also feature the contact information of the insurance company and a helpline number for policy-related queries.
How to Download a Health Card?
To download your health card for your Group Health Insurance Policy with Tata AIG, follow these simple steps:
Access via App
Employees can easily download their health card by accessing the Tata AIG app. Log in to your account, navigate to the Group Health Insurance section and download your health card directly from there.
Email Search
Alternatively, you can find your health card by searching your official email inbox. Look for an email from Tata AIG related to your Group Health Plan. The health card will be attached to this email.
Terminologies You Need to Know Before Buying a Group Health Insurance Policy
Before purchasing a group health insurance policy, it is essential to familiarise yourself with key terminologies to make an informed decision.
Here are important terms you should know:
Premium
The amount you pay periodically (monthly, quarterly, or annually) to the insurance company to maintain the group health insurance coverage.
Deductible
The predetermined amount that the insured individual or the group must pay out-of-pocket before the insurance coverage kicks in. Higher deductibles generally result in lower premium costs.
Copayment (Copay)
A fixed amount that the insured person must pay at the time of receiving healthcare services, such as doctor visits or prescription medications. The co-payment amount varies depending on the service and is often a set percentage or a fixed sum.
Network
A group of healthcare providers and hospitals that have agreements with the insurance company to provide services at negotiated rates. It is important to understand the network's size and the availability of preferred healthcare providers.
Pre-Authorisation
The process of obtaining approval from the insurance company before undergoing certain medical procedures or treatments.
Exclusions
Specific medical services, treatments, or conditions that are not covered under the group health insurance policy. It is crucial to review the list of exclusions to understand what is not covered by the policy.
Waiting Period
The duration during which certain benefits, such as coverage for pre-existing conditions or maternity benefits, may not be available. It is important to know the waiting period associated with different benefits.
Renewal
The process of extending the group health insurance policy beyond its initial term. Understanding the renewal terms and conditions, including any changes in coverage or premiums, is crucial.
Difference Between Group Health Insurance and Individual Health Insurance
Group health insurance and individual health insurance are two distinct types of health coverage that vary in terms of their eligibility, cost structure and coverage options. <br> Group health insurance refers to a policy provided by an employer or an organisation to cover a group of individuals, such as employees or members of an association. <br> In contrast, individual health insurance is purchased directly by an individual for themselves and their dependents. Here are some of the key differences between the two:
| Differentiating factors | Group Health Insurance | Individual Health Insurance |
|---|---|---|
Eligibility | It is primarily offered by employers to their employees as part of employee benefits. It covers all eligible employees and, in some cases, their dependents. | Individual health insurance is available to any individual, including self-employed individuals, unemployed individuals, or those not covered under group policies. |
Coverage | It generally provides standard coverage options determined by the employer. These plans often include basic hospitalisation, pre- and post-hospitalisation expenses, and some additional benefits. | Such plans offer a wider range of coverage options, including comprehensive coverage for hospitalisation, outpatient care, maternity benefits, critical illness coverage, and more. Individual policies can be customised to suit the specific needs of the insured. |
Cost Structure | These plans usually have lower premium costs compared to individual policies because the employer often subsidises a portion of the premium. The premium is shared between the employer and employees, making it a cost-effective option. | The premiums are solely the responsibility of the insured person and are based on factors such as age, medical history, and chosen coverage options. |
Portability | These plans are typically tied to the employer. When an employee leaves the organisation, the coverage may be lost unless they opt for portability or an individual policy. | Such plans are portable, allowing individuals to maintain coverage. |
Underwriting | These plans in India generally have simplified underwriting processes, with no or minimal medical underwriting requirements. | Here, the insurers may conduct more extensive underwriting, considering an individual's medical history, pre-existing conditions, and overall health to determine eligibility and premium rates. |
Frequently Asked Question
