Group Health Insurance

A congenital disease also called birth defects and congenital disability is a condition which is existed at or before the birth irrespective of cause.

Those disorders which are normally characterized by structural deformities are called congenital anomalies which mean, some defects in a developing fetus.

Further, congenital anomaly can be further divided under the following heads=

  1. Internal Congenital Anomaly – It is that type of congenital anomaly which is not visible in the accessible parts of the body.
  2. External Congenital Anomaly – It is the congenital anomaly which is on the visible parts of the body.

Usually, congenital disabilities can be due to the genetic or environmental factors. It comprises of errors of morphogenesis, chromosomal abnormality, infection, etc.

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Here the outcome of the disorder will rely on the complex interactions between pre-natal deficit and post-natal atmosphere.

Some of the congenital disorders are=

  • Albinism
  • Benjamin syndrome
  • Chromosome 22 Abnormalities
  • Cleft lip/palate
  • Fetofetal Transfusion
  • First arch syndrome
  • Gastroschisis
  • Goldenhar syndrome
  • Harlequin type ichthyosis
  • Heart disorders (Congenital heart defects)
  • Hemifacial Microsomia
  • Holoprosencephaly

In the case of group health insurance policies, most of the insurers keep congenital diseases under their exclusion list. However, the master policyholder, i.e., the one who has bought group health insurance, can get it covered under its group health insurance policy by paying the extra premium.

In some cases, the deductible can be applied to keep premium rates under check. In the insurance sector, the deductible is the amount that a policyholder would have to pay upfront before the insurer kicks in.

In some cases, it is easy to find out congenital disorder in a child before birth. Therefore, if you or your family have a history of the congenital disorder, you should go with a congenital test before conceiving. Read your group health insurance policy document as some insurers cover such tests as well, especially if they are offering maternity benefits.


In an engineering sector, L.K Engineering had carved a niche for itself. Employing over 500 employees, the company had its offices in four metro cities in India. In addition to giving benefits like paid vacation, crèche facility, etc.; the company had also started offering group health insurance policy a few years ago. Along with the benefits like maternity cover, parents’ coverage, wide network hospitals, etc.; the company’s group health insurance also covered congenital diseases.

Congenital diseases are those diseases which are there from birth. Considering the extra premium cost that L.K Engineering would have to bear due to congenital disease coverage, the company decided to offer it with a deductible limit. In this case, L.K Engineering introduced a deductible of Rs 10,000.

Last year, Manoj Singh who was working as a mechanical engineer in L.K Engineering approached the group health insurer with a claim of medical expenses which he spent on the treatment of congenital disease of his son, Ravish.

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Ravish, a 5-year-old had a congenital anomality of the heart, ‘atrial septal defect.’ Since his birth, Manoj was taking him to a doctor for monthly checkups. When last year, his condition deteriorated suddenly, Manoj took him to a nearby hospital where doctors started his treatment immediately. Here, Manoj paid all the medical expenses, which was Rs 50,000, and later filed for reimbursement under group health insurance policy.

As a group health insurer was covering congenital disease with a deductible of Rs 10,000, in this case, the insurer settled the medical expenses of Rs 40,000 (50,000-10,000) after checking all the medical reports and doctor’s prescription.

Usually, most of the group health insurance companies do not cover congenital disease, however, as L.K Engineering had paid an extra premium, the insurer agreed to provide coverage for this as well.

Further, the group health insurance policy was offering maternity cover also, i.e.; it was covering both pre and post-natal expenses. It means, all women employees who were expecting a child, can go for tests before to find any congenital disorders in the unborn child. The insurer would include test expenses under its maternity cover.

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