Group Health Insurance

What is maternity Benefit in Group Health Insurance
One of the key benefits that young employees value in the Group Health Insurance (Group Mediclaim) provided by the company is the Maternity Benefit.  There are several aspects to the Maternity benefit that should be considered, while designing and purchasing the group health insurance plan. These aspects are covered below:
How is maternity sum assured different from overall sum assured under group health insurance?
The maternity sum assured is different from the overall sum assured of the group mediclaim policy. This sum assured is fixed different for Normal and Caesarean delivery. Generally companies provide higher sum assured for Caesarean delivery.
The market average is to provide 25,000 sum assured for Normal and 35,000 for C-Sec delivery. While most Insurance companies limit the benefit to 50,000, some would provide as high as 100,000.
Group insurance policies for young groups typically carry maternity benefits. Hence HR managers need to evaluate carefully the extent of benefit to be offered.
What is application of co-pay on Maternity?
In case your policy has co-pay, it is generally not applied on the maternity claims. The rational being that benefit is already capped. However it is important for your Insurance Broker to clearly specify this in the policy terms, since ambiguity later can lead to claim disputes and employee dissatisfaction.
Cover for Abortion in Maternity?
Group Health Insurance generally does not cover self-inflicted, or fertility related treatment. Similarly voluntary abortion is not covered under Group Health Insurance by most Insurance companies. However emergency abortion i.e., for life saving purpose is covered by most insurance companies. It is important to note that each company has its own view on this, so important to get it clarified through your insurance broker.
Is the new born baby covered within maternity sum assured?
In a standard policy, a new born is not covered under the health insurance policy, unless it is atleast 90 days old (some companies increase the restriction to make it 150 days). However, one can get it customized to cover a new born from Day 1. Within this the employer has a choice to fix the sum assured for the new born for the period between 0-90 days. It can be either the maternity sum assured or the sum assured available to the employee. It is highly recommended that the higher sum assured should be chosen, since if any complication arises to the new born, the maternity sum assured would be highly inadequate.
What is the waiting period for maternity?
Some of the individual policies that offer maternity benefit, have a waiting period of 3-4 years. However in a Group Health Insurance (Group mediclaim) the waiting period comes down to 9 months i.e., the member should be atleast be enrolled in the policy for nine months. This condition for 9 months waiting period can also be waived if desired by the company. This would mean that from Day 1 of the policy, the enrolled members can claim the maternity benefit.
Is internal congenital disease covered under group health insurance?
It is a standard exclusion with most insurers. Again, this exclusion can be waived off and get it covered in the group insurance policy. Do note that all companies do exclude external congenital disease.
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