A Group Mediclaim (GMC) policy is the most common employee benefits policy for any company. It is a tailor-made program, i.e., it gives you complete choice in personalizing the benefits, terms, and conditions. Therefore, companies design policy benefits with features that appeal more to the target audience – the employees.
Following are the key points in a GMC Policy to be noted in policy design:
1. Cashless network hospital list –
Nowadays each health insurance policy provides a cashless service for hospitalization within the network. Before enrolling, it is important to check if the reputed hospitals in the neighborhood are on the network list. The higher the no. of network hospitals, the higher is the probability of an employee utilizing cashless service. This will ultimately improve the overall employee experience.
2. Sum Insured –
Sum insured determines the maximum responsibility of an insurance company. This responsibility is towards the medical expenses of the employee and his/her family for the period of insurance. Hence choosing an optimum sum insured is necessary so that in a medical emergency it does not hit the employee’s finances. The sum insured for each employee in a group insurance scheme can be flat or graded. Grading can be done on the basis of work, location, designation, service tenure, etc. We recommend choosing an average sum insured of 5L.
Additional read: Group Health Insurance
3. Room-Rent (Normal/ ICU) –
Insurers allow you to choose the room-rent limit in the policy. Traditionally, insurers have maintained 1% of the sum insured as the per-day limit for a normal room. For an ICU room, the limit is 2 % of the sum insured. But this pattern is fast-changing today where the average cost of a single-bedded AC room in a reputed hospital is 8K. Some insurers offer no-capping on room rent but we do not advise it as it can be misused by renting deluxe and suite rooms. We recommend you to opt for the Single AC room-rent category as a value-for-money choice.
4. Maternity –
You have the choice of covering maternity in a group policy. If you are a company with young staff members, there are high chances of utilization, hence you should consider it. Maternity is a capped benefit with limits for Normal and C-sec deliveries. You can either choose the same limit or a slightly higher limit for C-sec. The most common maternity limit is between 50-75K. Don’t forget to add coverage for pre and post-natal expenses in the maternity cover.
5. Baby Day One Cover –
This feature only exists in a group policy. The retail policies cover babies after 90 days from birth. Respiratory disorders and neo-natal jaundice are common health issues in newborns. Also, treatment requires hospitalization. You can opt-in for covering newborns from day one even if you do not include maternity in your group policy.
6. Disease-wise capping –
Insurers offer discounts in premium if you are opt-in for capping for common diseases like a kidney stone, hernia, cataract, etc. In case you opt-in for disease-wise capping, please ensure that the limit for each of these diseases is sufficient for treatment. For e.g, a limit of 30-35K per eye for cataract treatment is a sufficient limit. We advise you for disease-wise capping only if your insurance broker/consultant is experienced to suggest you the right limits.
7. Co-payment –
Co-payment refers to the part of an employee’s contribution towards a medical claim. For example, a co-payment of 10% would mean that the insurer would settle 90% of the medical claim bill and an employee would contribute the remaining 10%. Also, a 20% co-payment would mean that insurer would settle 80% of the bill and an employee would contribute the remaining 20%. Co-payment is a common feature in A GMC policy that cover parents/in-laws. It is to keep a check on both premiums and claims and to improve the sustainability of the policy.
Described above are the terms of the IPD/hospitalization-only policy. You can choose to cover OPD, vision and dental, medical check-ups, etc. These choices would be based on your overall budget and employment proposition.
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.
