A group health insurance policy is meant to offer coverage to a certain number of members who may belong to a same group in case of family floater health insurance policy. For instance, a group health insurance policy bought by a corporate means that the policy will cover all employees under a single policy.

Some group health insurance policies also extend coverage to family people of the members as well. In this case, if the coverage is available to family members as well, the total sum insured would be divided between all the covered family members. It means, family members will not get the coverage more than what the sum insured is. Also, no extra cover will be given to you as well.

The benefits of group health insurance will be provided up to the sum insured subject to any limits as stated in a policy document. It means, if one person exhausts the entire sum insured available under a policy then the other insured family members will have no sum insured left with them.

Some of the maternity benefits covered under group health insurance plans.

Read More: What are maternity benefits available in group health insurance plans?

The total sum insured will be reduced to the extent of use. It means if any of the family member makes use of group health insurance policy, the insurer will reduce the available sum insured to that extent. How one can file claim under group Insurance policy

Case

Working as a software engineer in M.J Tech, Rajiv Saran is living in Delhi with his wife and father. Apart from offering various benefits to its employees, M.J Tech is also offering group health insurance to its employees of coverage up to Rs 5 lakh. The best part is that the policy is being offered not only to employees but their family members as well.

In this case, Rajiv got group health insurance coverage for himself, his wife and father. Last year, his father had to be hospitalized after he suffered a cardiac arrest. Thankfully, doctors could save him. Here Rajiv decided to use group health insurance policy offered by his employer. The total sum insured offered by group health insurer was Rs 5 lakh and the medical bills came around Rs 6 lakh. Here, Rajiv asked his group health insurer to settle the bill and the insurer asked for documents like medical bill, doctor’s prescription, etc.

Read More: How to File a Claim Under Group Health Insurance Policy?

Rajiv took his father to a hospital which was not in the network of group health insurance policy, and therefore, the insurer asked him to pay the medical bills first and later approached it for the reimbursement.

Here, the insurer carefully reviewed all the documents submitted by Rajiv and settled the claim accordingly. As the medical bill was of Rs 6 lakh and the coverage was Rs 5 lakh, the insurer settled the claim up to the sum insured and the remaining was paid by Rajiv.

However, now the entire sum insured available under group health insurance was exhausted for the current year. It means, if Rajiv or his wife were hospitalized or need group health insurance cover, it won’t be available.

The similar thing happened when Rajiv had to be rushed to a hospital when he was hit by a car. Some passersby took him to a hospital, where doctors operated on him and saved his life. Here the medical bills came around Rs 2 lakh. After discharge, Rajiv approached his group health insurance company for the settlement of claims. However, the insurer refused to settle his claim as the entire sum insured was exhausted in a group health insurance policy.

It is interesting to note that group health insurance policy was offering coverage to Rajiv, his wife and father, however, the one sum insured was divided between all of them. It means, either the sum insured is equally divided among three of them or any one of them can exhaust the entire sum insured or use it as per the requirement and the same will be deducted from the total sum insured.

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