With disease-wise capping, an insurer can reduce claims out-go and hence its risk for the GMC. Though you can select the list of diseases and respective capping for a group policy insurers have pre-defined slabs of lower limits, default limits, and higher limits. Below is an illustration of these slabs –
Disease-wise capping can be used by group medical coverage (GMC) providers to manage prices and control costs associated with providing healthcare to a group of individuals. This approach involves setting limits or caps on the amount of money that can be spent on specific diseases or conditions, within the group coverage. By implementing these caps, the group medical coverage provider can help to control costs and ensure that the coverage remains affordable for the group members.
This approach can also be used to incentivize group members and medical facilities to provide efficient and cost-effective care, by promoting treatments that are within the cap. For example, if a member is able to treat a disease or condition within the cap, they would be able to save on out-of-pocket expenses. This approach can also help to promote transparency and fairness in the healthcare system, by making it clear to members and providers what they can expect to pay for a specific treatment or procedure.
Additionally, disease-wise capping can also help to ensure that healthcare resources are allocated in an efficient and equitable way, by prioritizing treatments for the diseases and conditions that are most critical or prevalent within the group. By capping costs on certain diseases, the group medical coverage providers can keep the overall premiums affordable and sustainable for the group members.
- Lower Limits –
| DISEASE-WISE SUB LIMITS | METRO | NON-METRO |
| Appendix | 12,000 | 10,000 |
| Eye related | 17,000 | 15,000 |
| Gall Bladder | 15,000 | 15,000 |
| Hernia | 12,000 | 10,000 |
| Hydrocele | 7,000 | 5,000 |
| Hysterectomy | 20,000 | 17,000 |
| Piles | 10,000 | 7,000 |
| Urinary Stone (incl DJ stent removal for same stone) | 30,000 | 25,000 |
| Joint Replacement including Vertebral joints (Per knee) | 75,000 | 70,000 |
- Default Limits –
| DISEASE-WISE SUB LIMITS | METRO | NON-METRO |
| Appendix | 20,000 | 18,000 |
| Eye related | 25,000 | 22,000 |
| Gall Bladder | 22,000 | 22,000 |
| Hernia | 20,000 | 18,000 |
| Hydrocele | 15,000 | 12,000 |
| Hysterectomy | 28,000 | 25,000 |
| Piles | 18,000 | 15,000 |
| Urinary Stone (incl DJ stent removal for same stone) | 35,000 | 30,000 |
| Joint Replacement including Vertebral joints (Per knee) | 85,000 | 80,000 |
- Higher Limits –
| DISEASE-WISE SUB LIMITS | METRO | NON-METRO |
| Appendix | 24,000 | 19,200 |
| Eye related | 30,000 | 25,200 |
| Gall Bladder | 30,000 | 25,200 |
| Hernia | 24,000 | 19,200 |
| Hydrocele | 18,000 | 14,400 |
| Hysterectomy | 33,600 | 28,800 |
| Piles | 19,200 | 15,600 |
| Urinary Stone (incl DJ stent removal for same stone) | 40,000 | 35,000 |
| Joint Replacement including Vertebral joints (Per knee) | 1,02,000 | 90,000 |
Premiums for higher disease-wise capping are more competitive among the lot in GMC.
Written By-
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.
