What are the general exclusions under group health insurance?

What are the general exclusions under group health insurance?

Happy employees are the most valuable assets of the company. It’s important to protect the well-being of employees and their family with various employer benefit package. As healthcare inflation is rising every year, health insurance works as a great form of compensation for employees. It not only benefits to the employees but also provides tax benefit for employers. The companies can hire and retain good employees by providing employee benefits in the form of group health insurance plans. 

What is group health insurance or group mediclaim coverage (GMC)? 

Group mediclaim coverage (GMC) is a type of group insurance that can be purchased by group of people to protect their and their families’ well-being. Group health insurance policies are also termed as employer-sponsored health insurance policies as it is purchased by employer for all the eligible employees of the company. Usually, these policies come at a reduced cost as insurance company’s risk is spread across all the group members. Facility of cashless hospitalisation is the major plus point of group health insurance policies. 

Group mediclaim policies can be availed by the following for their members/employees –

  • Societies, clubs or any other specific groups 
  • Companies of any size including small and medium enterprises. The coverage can be given for families also.
  • Associations
  • Financial and non-financial institutions, etc

What are the advantages of group insurance?

Group health insurance plans provide coverage for hospitalisation, day care procedures, and domiciliary hospitalisation, and pre & post hospitalisation cover, additional covers for the family under family floater clause including all the members of the family. As the policy provides coverage for major health uncertainties, it benefits the employee and their family very much in the time of need. Following are some of the advantages of group insurance.

  • Cost effective medical coverage for employees
  • Tax benefits on mediclaim premiums paid
  • Coverage under group mediclaim can be availed for all members 
  • Group health insurance plans can be customised based on the common requirements of the group
  • Cashless claim facility at the network hospitals
  • Coverage for every member of family without any prior medical check-ups
  • Coverage for pre-existing ailments
  • Waiver of waiting period for maternity benefits, new born baby cover and pre-existing illness cover.

Though the group health insurance policies offer wide range of healthcare benefits and coverage, it’s equally important to know what is not covered by these plans. In case of arrival of claim situation, knowing the scope of coverage along with limitations helps to place the claim rightly.

What are the exclusions under general health insurance policy?

Following are some of the permanent exclusions under health insurance policy –

  • Addictive conditions or alcohol/drug abuse

Expenses incurred for rehabilitation treatment for addictive conditions or any kind of alcohol or drug abuse are not covered by group insurance schemes for employees.

  • Alternative treatments

Expenses incurred for alternative treatments like Unani, homeopathy etc are not covered by most of the group health insurance policies.

  • HIV and AIDS

Treatment cost involved for sexually transmitted diseases such as HIV/AIDS are not covered under the policy. Conditions associated with HIV/AIDS are also excluded from group insurance schemes for employees.

  • Treatments outside the geographical limits

If treatment is availed outside the policy’s applicable geographical limit, then the coverage is not provided for such expenses incurred.

  • War

Treatment for Illness or injury that is directly or indirectly attributable to war, act of foreign enemies, invasion, hostilities (whether war be declared or not), commotion, civil war, rebellion, insurrection, revolution and military or usurped power are not covered under group mediclaim coverage.


  • Nuclear risk

Treatment for illness or injury that is directly or indirectly caused by nuclear weapons or materials is not covered under the policy.


  • Cosmetic treatments

Cosmetic and aesthetic treatments of any description such as plastic surgery, gender change surgery, and Lasik treatments are not covered under the policy.


  • Dental treatment

Any kind of dental treatment or surgery unless it was required due to accidental injury are not covered under the policy.


  • Self-inflicted injuries

Suicide, attempt to suicide and intentional self-injury are not covered.


  • Mental illnesses

Any expenses incurred for treating mental illness, stress, psychiatric or psychological disorders are not covered.


  • Unproven experimental treatments

Experimental, non-standard or unproven treatments that are not proven to be effective are not covered.


  • Congenital illnesses

Any expenses related to treatment of external and internal congenital illness, birth defects or anomalies are not covered.


  • Childbirth and fertility treatments

Healthcare expenses incurred for treatments arising from childbirth, miscarriage, abortion and other complications arising out of it are not covered. Treatment costs for fertility, sub-fertility, infertility, surrogate or vicarious pregnancy, birth control etc are not covered.


  • Hereditary conditions

Treatment for abnormalities, illnesses that are passed on though family genes are not covered under the policy.


  • Sleep disorders

Treatment costs for sleep disorders like sleep apnea and snoring etc. are not covered under the policy.


  • Developmental problems

Treatment cost involved in treating development issues such as learning difficulties, behavioural problems and attention deficit hyperactivity disorder etc are not covered under group insurance schemes for employees.


  • Unlawful activity

Breach of law or committing an act with criminal intent are excluded from group health insurance policies.

Click here to know more on exclusions of group insurance policy

For smoother operation and higher productivity, it’s important for every employer to protect their employees’ well-being. By providing a good amount of group mediclaim coverage to employees and their families’, companies can boost their employees’ morale which ultimately lead to business growth. Selecting the right insurance is all the more important. Click here to buy group health insurance plans

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