What you need to know about the Exclusions in Group Mediclaim Policies?

While as an employer, you might be thinking that it is essential to provide a safety health cover to your valuable employees, you must have come across several benefits of a Group Health Insurance. Most of these generalise the fact that in a group mediclaim policy, there are certain unique benefits that are often missing in an individual health insurance. So, the general features of a Group health cover might indicate that you and your employees are financially safe as the policy will take care of all the eligible employees’ health expenses. There is a clause of no or limited co-pay, no waiting period for critical illnesses and it may seem that everything under the sun or any treatment is covered in a Group mediclaim policy.

Well, if you as an employer or employee still think so, you need to take a closer look at the policy document and its wordings. This is because going deeper into these clauses will make you realise that there are multiple exclusions in a group Health insurance policy than is otherwise highlighted by your insurer or your agent. You need to delve deeper and ask such critical questions to your chosen insurer or agent before you make a decision to avail a particular policy for your employees’ benefits.

Proper research on the exclusions of the group health cover is necessary so that you can appropriately inform your employees regarding the same in order to avoid any confusion at the time of claim. If an employer is himself not informed about these exclusions, it can lead to misunderstanding and an employee might feel a breach of trust on behalf of the organisation. There is no fixed list of exclusions and the provisions of the policy can vary according to the insurer chosen. So, you need to look out for certain exclusions in the specific provisions in order to be well-aware of what is exactly applicable to be claimed in the policy.

Major Exclusions in Group Health Policies

  1. No Co-pay?

Generally, the features of most insurance policies would indicate that all the medical expenses incurred by the employee up to the sum assured for him in the group health cover will be borne by the insurer.

This may not be applicable in certain cases when some insurers might demand co-pay which is either fixed or varies per the location of the employee in India. For example, the co-pay clause might be applicable in metropolitan cities on varied rates but not in other cities.

  1. Waiting Period

Group health policies carry a short waiting period for admission of a new claim. This waiting period is applicable only in the first year of the policy unless the policy suffers a break in premium payment. It is also applicable for the pre-existing illnesses of the employees.

However, certain insurers keep a waiting period clause for the pre-existing illnesses which is applicable only if the policy has been renewed on time and been functional for at least 2 years.

Moreover, there is also waiting period applied for making the claim in certain surgeries like removal of tonsils. Only after the end of the waiting period, the claim can be made in such a case.

Existence of waiting period means that the employee suffering from any of these illnesses would have to continue his job at the same company for the period till which the waiting period exists. Therefore, employees needing special care should check with the employer about the cover.

  1. No Cover for AYUSH Treatments

Medical expenses of only allopathic treatments are generally covered in a Group mediclaim policy. Treatments of naturopathy, homeopathy and immunizations or vaccinations are generally not covered in the health policies by most insurers. Any expenses incurred for weight loss are not covered in Group Health policy.

  1. Other Exclusions: There may be certain specified exclusions in the policy wordings like…
  • Self-harm/injury.
  • Injuries caused due to any involvement in criminal activity.
  • Injury incurred due to being victim of a criminal act.
  • AIDS or HIV treatment is not covered
  • Cosmetic and plastic surgery unless suggested medically are not covered under the group mediclaim policies offered by most insurers.

The above are some of the exclusions which must be kept in mind before availing a group mediclaim insurance policy.

SecureNow Insurance Advisors offer quotes on group policies from multiple insurers and can help you arrive at a decision by comparing the features of different policies. SecureNow also offer 24×7 support in management of the policies.

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