Group Health Insurance

Important things to know about GMC

A group mediclaim insurance plan is a good way to ensure health insurance coverage for the members of a group at affordable premiums. The policy can be easily availed of, and it covers all the members of the group under a single policy. There are various aspects of the plan which should be kept in mind before you buy the policy. Insurance is a technical concept and a complete grasp of the policy helps you understand the policy benefits and exclusions. So, here are some important things to know about group mediclaim plans –

  • Eligibility of the group

Group mediclaim plans are available only to those groups which are recognized and which exist for any reason except to get insurance. If a group is formed only for the purpose of availing group insurance coverage, such a group would not be eligible to avail a group health insurance plan. Common groups which are eligible to avail group mediclaim include the following –

  • Trade unions
  • Employer-employee groups
  • Clubs
  • Banks and financial institutions 
  • Associations
  • Debtor-creditor groups, etc.

Moreover, there is a minimum number of members who are required to be covered to avail a group mediclaim policy. This number can range from twenty to thousands of members.

  • Eligibility of the insured members

Any individual who is part of the group buying the insurance policy would be covered under it. There are no specific eligibility parameters for different group members under an employee mediclaim policy. If the individual is a part of the group, he/she can get coverage. The individual would not even have to undergo any medical check-ups to get coverage. Moreover, in many instances, the coverage can also be extended to cover the dependents of the insured members. Dependents, in this case, would include the spouse, dependent children and dependent parents. 

  • Premium and coverage 

Since all the members of the group are offered health insurance irrespective of their health and medical conditions, the coverage under the policy is usually determined by the insurance company. 

The company assesses the type of group availing coverage and the composition of its members when determining the coverage and premium. Coverage might be decided based on the age or income of the members of the group. 

Once the coverage is determined, the premium is calculated. The premium can be paid by the group itself in which case the coverage would be free for the members. Alternatively, the members can contribute their respective premiums to the group or they can pay a part of the premium themselves and the remaining can be funded by the group. Whatever be the mode of premium payment, the insurance company collects a single premium from the administrator of the group when the policy is issued.

  • Term of coverage 

Group mediclaim plans are offered for one year. Every year the policy is renewed after it is underwritten by the insurance company again. Underwriting of the policy every year is required because the group’s composition might change and also to take into consideration the group’s claim history in the last year. If the group has made a limited number of claims, the insurance company also allows premium discount when the policy is renewed. So, to avail non-stop coverage under the policy, the group is required to get the policy renewed every year within the due date.

Additional Read: How the renewal pricing is done under group mediclaim plans

  • Payment of claims

Group medical policies do promise cashless claim settlements if the treatments are taken at a network hospital. During the duration of the policy, if any insured member is hospitalised, the insurance company should be informed. The insurance company would then pay the claim for the insured member up to his/her coverage limit. The cover for other members, however, would not be affected. Any member facing a claim can report the claim to the insurance company for settlement while the other members can enjoy undisturbed coverage. 

  • Coverage 

Coverage under the policy is allowed for the following medical costs –

  • Hospitalisation costs which include room rent, doctor’s fee, surgery cost, medicines, blood, etc.
  • Pre and post hospitalisation costs
  • Day care treatments
  • Organ donor expenses
  • Ambulance charges
  • Domiciliary treatment costs, etc.

Moreover, group medical plans also provide add-on coverage options which can be chosen at an additional premium. Common add-ons available under group health policies include the following –

  • Maternity cover
  • Critical illness cover
  • Coverage for dependent family members
  • Personal accident cover, etc.


  • Exclusions 

Just like in the case of normal health insurance plans, group mediclaim plans too have a list of exclusions which are not covered under the policy. Some of the common exclusions include the following –

  • Cosmetic or psychiatric treatments
  • HIV/AIDS infection
  • Injuries or illness suffered due to war, riots, nuclear contamination, etc.
  • OPD expenses
  • Naturopathy treatments or any other unproven treatments
  • Pre-existing illnesses are not covered in the first few years of the policy

You should, therefore, know these exclusions to understand what is covered under the plan.

A group mediclaim policy provides good coverage benefits at low premium rates. However, you should know about the above-mentioned aspects of the policy to understand the policy benefits and its terms and conditions. 

As you understand how group mediclaim plans work, it would be easy for you to enjoy coverage and make a claim under the policy when you face medical expenses. So, understand the aspects of insurance and buy the policy to cover your group members under affordable health insurance coverage. 

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