Group Health Insurance

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A waiting period in the group health insurance refers to a span of time which needs to be covered before the listed ailments covered under this policy begins to get covered. There are three different types of waiting period:

  • Commencement of health insurance plan
  • Pre-existing disease coverage
  • Maternity waiting period

For the commencement of the group health insurance policy, the waiting period will be 30 to 90 days after the insurance plan is taken. This is also known as the initial waiting period and, usually, depends on the insurance company’s internal policy. But in the group health insurance, this waiting period can be waived off.

Read More: What is Domiciliary Hospitalization in Health Insurance Policies?

For the pre-existing disease coverage, the waiting period is usually four years. Once the waiting period is done, the insurance company cannot deny a claim to the holder.

The way this clause functions is easy. Before taking the policy, the insured declares his/her pre-existing disease/ailments such as diabetes, thyroid, high blood pressures, etc. Based on the disease/ailments declared, the insurance company will decide whether a cover under the group health insurance can be offered or not.

When they accept to cover these disease/ailments, the insurance company will usually impose a waiting period of 4 years, which means that only after the four years of the waiting period is over can the insured claim any medical expenses.

There are however certain ailments such as ENT related disorders, osteoporosis, hernia and others for which the waiting period can be one or two years. And this waiting period also can be waived off if desired by the group policyholder.

As for the maternity waiting period, this is quite standard for most of the insurance companies. The waiting period ranges from 9 months to 36 months. And as for the other waiting periods, the maternity cover waiting period also can be waived off in a group health insurance policy so that the person is covered from day 1 of the policy.

Case: 1

30- year old Ranjan Desai joined M.K.M Engineering Company in 2013 as a senior engineer. Along with the various perks, his company also offered him a group health insurance. Ranjan knew that his current lifestyle made him more vulnerable to ailments which could also burn a hole in his pocket and therefore, he was happy to get the employer health insurance coverage. He was confident that his employer would cover him for his medical expenses in the future.

But just a week of joining M.K.M Engineering, Ranjan was diagnosed with a kidney stone and was advised to go for a Lithotripsy (surgery for removing stone). He told about his medical condition to his boss who granted him ten days leave for the surgery and recovery.

Ranjan was confident that his group health insurance policy would cover his medical expenses, and therefore, without reading the policy document or checking the facts, he got admitted and went for the surgery. In this case, Ranjan paid all the medical expenses and then approached his group health insurance company for the reimbursement.

Read More: What happens if a Group Health Policy is cancelled?

However, he got a major shock when his group health insurer rejected the claim and cited the reason that as he hadn’t completed the initial waiting period under a group health insurance policy, his claim would not be accepted.

Actually, there was a waiting period of 30 days in a group health insurance policy for new employees. It means the group health insurer will not cover any medical expenses incurred during the first month of joining. As Ranjan got hospitalised after a week of joining, his claim was rejected under a group health insurance policy as the waiting period was still not over.

Case: 2

It was in 2015 when Rita Mahajan joined M.K.M Software as a technical analyst. On the day of her joining, she had an induction training in which the HR Manager told her about the company’s policy along with the various benefits which all employees will be entitled to get.

One such benefit that M.K.M Software was offering was group health insurance policy. Elaborating more on the importance of the policy, HR Manager said, “As the medical cost is increasing at a dangerous rate, our group health insurance will help you by covering your medical expenses. We have no waiting period clause in our policy. It means you all are eligible to get the benefits of a group health insurance policy from your Day 1 in M.K.M Software.”

It means, if God forbid, tomorrow Rita incurs medical expenses, she can get them settled under a group health insurance policy. Without a waiting period, Rita is entitled to get coverage from the Day 1. All her medical expenses will be covered unless they are specifically excluded from the policy.

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