General exclusions under group health insurance
With healthcare costs rising every year, health insurance is a great form of compensation for employees. Additionally, group health insurance plans provide tax benefits for employers and help them hire and retain good employees.
Employers purchase group health insurance policies for all their eligible employees. Such policies usually cost less than individual policies since the insurance company’s risk is spread across all group members.
Group medical insurance plans offer
- Cost-effective medical coverage for employees and their families without prior medical check-ups
- Waiver of waiting period for maternity benefits, new-born baby cover, and pre-existing illness cover
- Coverage for pre-existing ailments
- Cashless claim facility at network hospitals
- Customization based on the common requirements of the group
- Tax benefits on mediclaim premiums paid by employers
Additional Read: Why should startups buy Group Health Insurance?
General exclusions under group health plans
Although group health insurance policies offer a wide range of healthcare benefits and extensive coverage, it’s important to know what these plans do not cover. In the following paragraphs, we discuss some typical exclusions of group mediclaim policies. Do note that these exclusions can be done away with on payment of additional premiums.
Employee insurance schemes sometimes exclude treatments sought for certain conditions. These include addictions and alcohol or drug abuse as well as sexually transmitted diseases such as HIV/AIDS and associated conditions. Other exclusions are an attempt to suicide or intentional self-harm and stress, psychiatric or psychological disorders. Additionally, group medical insurance may exclude congenital illnesses. Even within congenital diseases, a demarcation is made between internal congenital issues and external congenital diseases. Sometimes internal congenital is covered. Similarly, insurers frequently exclude sleep disorders, learning difficulties, behavioral problems, and attention deficit hyperactivity disorder.
Many group medical insurance policies do not provide coverage for alternative treatments like unani, homeopathy, etc. Similarly, coverage is rarely provided for experimental, non-standard, or unproven treatments. In addition, insurers tend to specify a policy’s applicable geographical limit and do not cover treatment outside this limit. Also, group health insurance plans do not cover cosmetic or aesthetic treatments like plastic surgery, gender-change surgery, and routine Lasik. Likewise, insurers do not provide coverage for dental treatments and treatments for infertility, surrogate pregnancy, birth control, etc. Some procedures involving robotic surgery or stem cell treatment may also be excluded.
Insurers often exclude injuries resulting from participation in dangerous sports. Sometimes, insurers also exclude snakebite or animal bite. Typically, insurance providers also exclude persons on duty with military, police, or paramilitary organizations. These occupations can be covered but must be properly captured in the policy. Group mediclaim policies rarely cover illness or injury directly or indirectly resulting from war and similar military action or caused by nuclear weapons or materials. Insurers also exclude treatment for injuries sustained while committing criminal acts.
Additional Read: What you should know about the exclusions of group insurance policy
In spite of these general exclusions, group health insurance policies for employees offer distinct coverage advantages. Moreover, by offering good group health insurance, companies can attract and retain good employees.
Case study: Exclusion for unrelated expenses
Jayant Gupta was working in LKC Construction as a senior technical analyst. The company offered comprehensive group health insurance to all its 500 employees and their family members.
Last year, Jayant’s father had a heart attack. Jayant approached the insurer with the medical expenses he incurred on his father’s hospitalization. The insurer covered all the medical expenses. However, when Jayant made a claim for the purchase of a wheelchair for his father, the insurer denied this claim. The insurer noted that this was an expense Jayant had incurred on durable items not related to the medical treatment for which his father had been hospitalized.
As an employer, if you are looking for a good medical insurance plan for your employees, get in touch with SecureNow. Do note that we can customize your insurance to waive off exclusions.