Group Health Insurance

How does a GMC policy work?
Quality healthcare in our country has become an exorbitantly expensive affair. As per a recent report by Mercer Marsh Benefits, the medical trend rate in our country is pegged at 10%. This will be double the overall inflation of 5%. Medical Trend Rate indicates the increase in per-person cost as a result of medical inflation.
Hence, most people are trying to find good and economical ways to supplement their individual health insurance plans so as to be able to secure their (and the family’s) physical well-being. Group Medical Coverage or GMC can be a great help or support for this purpose.
A GMC is a kind of group healthcare plan which is made available to a large group of employees. It is usually offered by organizations to its employees or a group to its members. The benefits available in such health insurance plans are usually the same for all members or remains constant as per the level of members. All the members are covered under one single policy.
The following are usually covered under Group Medical health insurance plans:

  • Hospitalization expenses

Expenses incurred during the stay in the hospital such as room rents, nursing, doctor’s fees, anesthesia, operation theatre charges, surgical procedures, etc. Usually, a hospital stay of at least 24 hours is required to make claims for these expenses. 

  • Pre and Post Hospitalization Expenses

The policy also takes care of expenses incurred before the hospital admission as well as post-discharge. The tenure of the pre and post-hospitalization period varies from one insurance provider to another. Usually, it is in the range of 30 and 60 days.

  • Cost for daycare procedures

With numerous technological advancements in the healthcare sector, certain treatments can be completed in less than 24 hours. These include treatments for cataracts, tonsillectomy, angiography, etc. These treatments are included in the scope of the GMC.

  • Domiciliary hospitalization

In certain situations, medical treatments are carried out at home due to the unavailability of hospital beds, etc. In such scenarios, group health insurance covers domiciliary hospitalization expenses as well. 

  • Add-on covers

Employers can opt for additional benefits as per their workforce demographics and needs. These include the inclusion of pre-existing illnesses, cost of external aids such as spectacles, dental treatment, increase in sum insured, etc.

  • Cashless facility

The policyholders can get cashless treatments at any of the hospitals in the provider’s network. Some pre-authorization formalities need to be completed for availing this benefit.

  • Maternity Cover

Most of the Group Health Insurance policies offer maternity benefits to their employees and their spouse. It covers expenses for procedures or treatments related to childbirth (including miscarriage and post-delivery complications)

Salient Features of GMC 
These are the key highlights of the group insurance scheme for employees.

  • Lower cost

One of the biggest advantages of group insurance is that their premium is significantly lower than individual healthcare plans. As a large number of people are covered through a single policy, the insurance provider is able to bring down the cost of insurance. 

  • Co-Payment

Most organizations bear (either wholly or partially) the insurance cost in GMC policies. Even in case of a co-pay arrangement, the employee ends up getting a higher coverage by paying only a nominal amount. Employers pay the bigger chunk of the premium such as 80-20. (80% being the employer’s share)

  • Medical Check-Ups

The policyholders do not need to go for any medical examination in order to be covered under the GMC. All employees are by default covered under their company’s health insurance policy from their day of joining. This benefit continues until they are a part of the organization.

  • Flexibility

Organizations offering GMC can customize the policy terms and riders. For instance, if they feel that the majority of the employees have aged parents to take care of they can include a top-up facility or remove any upper limit for policy enrollment for parents. 

  • Assistance

Just like HNIs get a dedicated wealth manager, organizations offering GMC get a policy SPOC. This is due to the volume of business associated with one single policy. Employees can reach out to the SPOC to get their queries resolved or seek assistance during hospitalization.

Claims Procedure
Like individual health insurance plans, there are two types of GMC Claims – Cashless or Reimbursement.

  • Cashless 

Cashless claims are entertained for network hospitals. The insured needs to complete some pre-authorization formalities in case of planned hospitalization. For emergency cases, they can liaise with their insurance SPOC. Alternatively, they can provide the insurance details to the hospital and they co-ordinate with the insurance company.

  • Reimbursement

In these claims, the insured takes care of all the expenses. Post-discharge they file the claim for reimbursement with the insurance company.
However, for group insurance claims the paperwork is comparatively easier. Mostly the members or employees can reach out to a SPOC or intermediary, rather than dealing with the insurance company.
An important point to note about group insurance schemes is that they do not have lifelong validity. The employees/ members remain covered under the policy as long as they remain part of the organization or group. Hence, if one changes employers or exits from the group, they cannot claim healthcare benefits as per the policy.
As a result, one should not rely solely on a group insurance scheme for their healthcare needs. It is a great way to increase its insurance cover or supplement their personal health insurance policies. 
It is important to read all the terms and conditions of the policies to ensure that you make the most of the benefits.

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