Group Health Insurance

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It is possible that in reading insurance policy documents, you have encountered the term ‘congenital diseases’. This post attempts to help you understand the term better and situate it in the context of group medical insurance.

Congenital disease — nature and types

Diseases that exist at the time of or from before birth are referred to as congenital diseases. These diseases are often characterized by congenital anomalies, which are usually of two types: internal and external.

An internal congenital anomaly is one that is not easily visible. On the other hand, an external congenital anomaly is clearly visible. Congenital diseases can have genetic or environmental causes.

The outcome of congenital disorders depends on interactions between pre-natal deficit and post-natal atmosphere. Congenital disorders include 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, and holoprosencephaly.

Read More: Are group health insurance premiums tax-deductible?

Group Health Insurance cover for congenital diseases

Most group health insurance policies list congenital diseases under exclusions. However, the employer or the head of the group can ask for congenital diseases to be covered under the group mediclaim policy by paying an additional premium.

In some cases, a deductible can be applied to keep premium rates under check. Deductible refers to the amount a policyholder would have to pay upfront; the insurer will only pay the remaining.

It is easy to check for some congenital disorders before birth. If there is a history of congenital disorders in the family, individuals can opt for prenatal screening. Some insurers cover such tests as well, especially if they offer maternity benefits.

Case study: Customising cover for congenital diseases  

LK Engineering started offering group health insurance a few years ago. Along with maternity benefits, coverage for parents, and a wide network of hospitals, the company’s employee health insurance scheme also covered congenital diseases. Considering the extra premium that would accrue for covering congenital diseases, the company decided to offer it with a deductible limit of Rs 10,000.

Read more: General exclusions under group health insurance

Last year, Manoj Singh, a mechanical engineer in LK Engineering approached the group health insurer with a claim for medical expenses incurred on the treatment of his five-year-old son, Ravish. The boy had a congenital heart anomaly, atrial septal defect, which required monthly check-ups from the time of his birth. Last year, Ravish’s condition deteriorated suddenly. Manoj took him to a nearby hospital where doctors started treatment immediately. Manoj paid all the medical expenses, which totaled Rs 50,000. Later, he filed for reimbursement under the group health insurance policy.

The insurer had a deductible of Rs 10,000 for congenital diseases. So, they settled the medical expenses of Rs 40,000 (Rs 50,000 minus Rs 10,000) after checking the medical reports and doctor’s prescriptions. Usually, most group health insurance providers do not cover congenital diseases. However, LK Engineering had paid an additional premium for coverage of congenital diseases.

The group health insurance policy also offered maternity cover for pre-and post-natal expenses. Thus, the insurer would reimburse pregnant female employees or spouses of male employees for screening for congenital disorders. The insurer included test expenses in its maternity cover.

You could customize your group health insurance policy to include congenital diseases and other exclusions. Give us a call at +91 9696683999 for help in picking the best policy and tailoring it to your needs.

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