While as an employer, you might think that it is essential to provide a safety health cover to your valuable employees, you may have come across several benefits of a Group Health Insurance. Most of these mention the fact that in a group mediclaim policy, there are certain unique benefits that are often missing in an individual health insurance. So from the general features of a Group health cover you may believe that you and your employees are financially safe as the policy will take care of all the eligible employees’ health expenses. There is a clause of zero or limited co-pay, no waiting period for critical illnesses and medical treatment costs which are covered in a Group mediclaim policy.
If you are an employer or employee, you should take a closer look at the policy document and its wordings. This is because you will soon realise that there are multiple exclusions in a group mediclaim insurance policy. You need to delve deeper and ask critical questions to your chosen insurer or agent before you make a decision to avail of a particular policy for your employees’ benefits.
Proper research on the exclusions of the group health cover is necessary so that you can appropriately inform your employees regarding the same in order to avoid any confusion at the time of claim. If an employer is himself not informed about these exclusions, it can lead to misunderstanding and an employee might feel a breach of trust on behalf of the organisation. There is no fixed list of exclusions and the provisions of the policy can vary according to the insurer chosen. So, you need to look out for certain exclusions in the specific provisions in order to be well-aware of what is exactly applicable to be claimed in the policy.
Major Exclusions in Group Health Insurance Policies
- Co-payment Clause:
Generally, the features of most insurance policies would indicate that all the medical expenses incurred by the employee is covered up to the sum assured in the group health policy.
This may not be applicable in certain cases when some insurers might demand co-payment which is either fixed or varies per the location of the employee in India. For example, the co-pay clause might be applicable in metropolitan cities on varied rates but not in other cities.
- Waiting Period
Group health policies carry a short waiting period for admission of a new claim. This waiting period is applicable only in the first year of the policy unless the policy suffers a break in premium payment. It is also applicable for the pre-existing illnesses of the employees.
However, certain insurers keep a waiting period clause for the pre-existing illnesses which is applicable only if the policy has been renewed on time and been functional for at least 2 years.
Moreover, there is also a waiting period applied for making the claim in certain surgeries like removal of tonsils. Only after the end of the waiting period, the claim can be made in such a case.
Existence of waiting period means that the employee suffering from any of these illnesses would have to continue his job at the same company for the period till which the waiting period exists. Therefore, employees needing special care should check with the employer about the cover.
- Other Exclusions: There may be certain specified exclusions in the policy wordings like…
- Injuries caused due to any involvement in criminal activity.
- Injury incurred due to being the victim of a criminal act.
- AIDS or HIV treatment is not covered
- Cosmetic and plastic surgery unless suggested medically are not covered under the group mediclaim policies offered by most insurers.
The above are some of the exclusions which must be kept in mind before availing a group mediclaim insurance policy.