What are the general exclusions under group health insurance?
Happy employees are the most valuable assets of the company. It’s extremely important, generally speaking, to protect the well-being of employees and their families with various employee benefit packages. As healthcare inflation is rising every year, health insurance works as a great form of compensation for employees. It not only benefits the employees but also provides tax benefits for employers. The companies can hire and retain good employees by providing employee benefits in the form of group health insurance plans.
What is group health insurance or group mediclaim coverage (GMC)?
Group mediclaim coverage (GMC) is a type of group insurance that can be purchased by a group of people to protect themselves and their families’ well-being. Group health insurance policies are also often employer-sponsored health insurance policies as they are purchased by employers for all the eligible employees of the company. Usually, these policies come at a reduced cost as the insurance company’s risk is spread across all the group members. Facility of cashless hospitalisation is the major plus point of group health insurance policies.
Group mediclaim policies can be availed by the following for their members/employees –
- Societies, clubs or any other specific groups
- Companies of any size including small and medium enterprises. The coverage can be given for families also.
- Financial and non-financial institutions, etc
What are the advantages of group insurance?
Group health insurance plans provide coverage for hospitalisation, day care procedures, and domiciliary hospitalisation, and offer pre & post hospitalisation cover for specified numbers of days, additional covers for the family under family floater clause including all the members of the family. As the policy provides coverage for major health uncertainties, it benefits the employee and their family very much in times of need. The following are some of the advantages of group insurance.
- Cost effective medical coverage for employees
- Tax benefits on mediclaim premiums paid for the employer
- Coverage under group mediclaim can be availed for all members
- Group health insurance plans can be customised based on the common requirements of the group
- Cashless claim facility at the network hospitals
- Coverage for every member of family without any prior medical check-ups
- Coverage for pre-existing ailments
- Waiver of waiting period for maternity benefits, new born baby cover and pre-existing illness cover.
Additional Read: Why should startups buy Group Health Insurance?
Though the group health insurance policies offer a wide range of healthcare benefits and coverage, it’s equally important to know what is not covered by these plans. In the case of a claim situation, knowing the scope of coverage along with limitations helps to place the claim rightly.
What are the exclusions under general health insurance policy?
Following are some of the permanent exclusions under health insurance policy –
- Addictive conditions or alcohol/drug abuse
Expenses incurred for rehabilitation treatment for addictive conditions or any kind of alcohol or drug abuse are not covered by group insurance schemes for employees.
- Alternative treatments
Expenses incurred for alternative treatments like Unani, homeopathy etc are not covered by most of the group health insurance policies.
- HIV and AIDS
Treatment cost involved for sexually transmitted diseases such as HIV/AIDS are not covered under the policy. Conditions associated with HIV/AIDS are also excluded from group insurance schemes for employees.
- Treatments outside the geographical limits
If treatment is availed outside the policy’s applicable geographical limit, then the coverage is not provided for such expenses incurred.
Treatment for Illness or injury that is directly or indirectly attributable to war, act of foreign enemies, invasion, hostilities (whether war be declared or not), commotion, civil war, rebellion, insurrection, revolution and military or usurped power are not covered under group mediclaim coverage.
- Nuclear risk
Treatment for illness or injury that is directly or indirectly caused by nuclear weapons or materials is not covered under the policy.
- Cosmetic treatments
Cosmetic and aesthetic treatments of any description such as plastic surgery, gender change surgery, and Lasik treatments are not covered under the policy.
- Dental treatment
Any kind of dental treatment or surgery unless it was required due to accidental injury are not covered under the policy.
- Self-inflicted injuries
Suicide, attempt to suicide and intentional self-injury are not covered.
- Mental illnesses
Any expenses incurred for treating mental illness, stress, psychiatric or psychological disorders are not covered.
- Unproven experimental treatments
Experimental, non-standard or unproven treatments that are not proven to be effective are not covered.
- Congenital illnesses
Any expenses related to treatment of external and internal congenital illness, birth defects or anomalies are not covered.
- Childbirth and fertility treatments
Healthcare expenses incurred for treatments arising from childbirth, miscarriage, abortion and other complications arising out of it are not covered. Treatment costs for fertility, subfertility, infertility, surrogate or vicarious pregnancy, birth control etc are not covered.
- Hereditary conditions
Treatment for abnormalities, illnesses that are passed on through family genes are not covered under the policy.
- Sleep disorders
Treatment costs for sleep disorders like sleep apnea and snoring etc. are not covered under the policy.
- Developmental problems
Treatment costs involved in treating development issues such as learning difficulties, behavioural problems and attention deficit hyperactivity disorder etc are not covered under group insurance schemes for employees.
- Unlawful activity
Breach of law or committing an act with criminal intent are also excluded.
Additional Read: What you should know about the exclusions of group insurance policy
For smooth operations and high productivity, it’s important for every employer to protect their employees’ well-being. By providing a good amount of group mediclaim coverage to employees and their families, companies can boost their employees’ morale which ultimately leads to business growth.