Group Health Insurance

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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.

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.

If you are looking for an ideal group health insurance policy, do reach out to us at