Group mediclaim is a good way to ensure health insurance coverage for the members of a group at affordable premiums. The policy is easy to buy and covers all group members under a single policy. However, you should keep in mind some features of these plans before you buy them. Insurance is a technical concept and a complete grasp of the policy helps you understand benefits and exclusions.
Key Takeaways
Purpose-Driven Groups: You cannot form a group solely to buy insurance. The group must be a recognized entity, such as a workplace, a bank’s customer base, or a professional association.
Universal Onboarding: The lack of medical check-ups means that every member of the group—regardless of their current health status—is automatically eligible for the same base level of protection.
Annual Underwriting: Because the “composition” of a group (the ages and number of people) changes every year, the insurance company re-evaluates the risk and sets a new premium every 12 months.
Comprehensive Inclusions: Beyond standard hospital beds and surgery, these plans often cover modern necessities like Day-care treatments (surgeries under 24 hours) and Organ donor expenses.
Strategic Add-ons: Organizations can choose to “beef up” their policy by adding riders for maternity, critical illness, or personal accidents, though these will proportionately increase the premium.
Eligibility of groups
A group health insurance plan is only available to recognised groups that exist for reasons other than to get insurance. Thus, a group formed only to avail group insurance coverage is ineligible for the same. Common groups eligible for group mediclaim are trade unions; employer-employee groups; clubs; banks and financial institutions; associations; debtor-creditor groups, etc.
To be eligible for group health insurance, groups must have atleast 20 members. However, in some cases it is possible to get cover for smaller groups as well.
Eligibility of members
There are no specific eligibility parameters for different group members in group mediclaim. In fact, if the individual is part of the group, they can get coverage. The individual does not even have to undergo medical check-ups to be eligible for coverage. Moreover, groups can choose to extend coverage to the dependents of insured members. This would include spouses, dependent children, and dependent parents.
Premium and coverage
Since all group members get health insurance irrespective of age and medical conditions, the insurance company usually determines coverage. So, they assess the type of group and its composition when determining coverage and premium. They might decide on coverage based on the age or income of group members.
Once the insurer determines coverage, they calculate the premium. The group can pay the premium, making coverage free for the members. Alternatively, members can pay their premiums or pay a part of it while the group funds the remaining. However, the insurance company collects a single premium from the group administrator when it issues the policy.
Period of coverage
Insurers offer group health insurance plans for one year. They then underwrite it again, after which it can be renewed. Underwriting every year is essential because the group’s composition might change. It also helps take into consideration the group’s claim history in the past year. A limited number of claims might lead to a premium discount at renewal. To avail of non-stop coverage under the policy, the group must renew the policy every year within the due date.
Additional Read: How the renewal pricing is done under group mediclaim plans
Payment of claims
Group medical insurance policies offer cashless claim settlements at network hospitals. For the duration of the policy, the insured member must inform the insurer of hospitalisations, if any. The insurance company will then pay the claim up to the coverage limit. The cover for other members will not be affected.
What is covered
Coverage under the policy is usually allowed for the following:
- Hospitalization costs include room rent, doctor’s fee, surgery cost, medicines, blood, etc.
- Pre- and post-hospitalization costs
- Day-care treatments
- Organ donor expenses
- Ambulance charges
- Domiciliary treatment costs, etc.
Group health insurance plans also provide add-on coverage options for an additional premium. Common add-ons available under group health policies include maternity cover; critical illness cover; coverage for dependent family members; personal accident cover, etc.
What is excluded?
As in the case of other health insurance plans, group mediclaim plans also have a list of exclusions. These include:
- Cosmetic or psychiatric treatments
- HIV/AIDS infection
- Injuries or illnesses suffered due to war, riots, nuclear contamination, etc.
- OPD expenses
- Naturopathy or any other unproven treatments
A group mediclaim policy provides good coverage benefits at low premium rates. However, it is helpful to understand the various aspects of the policy to be aware of your benefits as well as terms and conditions. This will make it easier to make a claim under the policy when needed.
Summary Table: Group Health Insurance Essentials
| Feature | Details |
| Group Eligibility | Must exist for reasons other than insurance (e.g., employees, unions, clubs). |
| Member Eligibility | All active members are covered; no medical check-ups required. |
| Minimum Size | Generally 20 members, though smaller “micro-groups” are possible. |
| Policy Tenure | Valid for one year; requires annual underwriting and renewal. |
| Premium Payment | Collected as a single lump sum from the group administrator. |
| Claim Facility | Cashless settlement at network hospitals up to the coverage limit. |
| Dependent Cover | Optional extension to spouses, children, and dependent parents. |
If you are looking for an ideal group health insurance policy, do reach out to us at support@securenow.in
Frequently Asked Questions (FAQs)
1. Can five friends form a “group” to buy this insurance?
A) No. To be eligible, the group must be a “recognized group” that exists for a primary purpose other than insurance, such as an employer-employee relationship or a registered trade union. A group formed just to get a discount is considered ineligible.
2. Does one person’s large medical claim reduce the coverage for others?
A) No. In a standard group health policy, every member has their own individual “Sum Insured.” If one person exhausts their limit, the coverage for the remaining 19 or 100 members remains completely unaffected.
3. What is “Domiciliary Treatment” mentioned in the coverage?
A) Domiciliary treatment refers to medical care for an illness that would normally require hospitalization but is instead provided at home because the patient’s condition prevents moving them to a hospital, or because a hospital bed is unavailable.
4. Why is the premium different every year at renewal?
A) Insurers look at two things during renewal: the current “Age and Count” of the members and the “Claim History” of the previous year. If the group had very few claims, they might receive a discount; if claims were high, the premium might increase.
5. Are “OPD Expenses” like standard doctor consultations covered?
A) Usually, standard group health insurance is an “In-patient” policy, meaning it covers expenses only if you are hospitalized for at least 24 hours. OPD (Out-Patient Department) expenses like routine consultations are typically excluded unless a specific “OPD Rider” is purchased.
About The Author
Mayank Sharma
MBA Finance
He is a professional who brings extensive knowledge and expertise to the field of group health insurance. He has dedicated 7years to helping individuals and businesses navigate the complexities of insurance. Having worked closely with numerous clients and insurance providers, he deeply understands the nuances of group health insurance policies. With a reputation for providing insightful and informative content, he leverages his industry experience to educate readers about the importance of group health insurance and its benefits. Through their articles, Mayank Sharma aims to empower individuals and businesses to make informed decisions about their healthcare coverage, ultimately promoting healthier and more secure communities.
