Health Insurance

Group Health Insurance: Coverage, Exclusions, and Claim Process

Living a healthy life is a challenge today due to the changes in lifestyle and stress. Medical emergencies can put stress on your finances and can become a hassle for your family. One way to manage…

Living a healthy life is a challenge today due to the changes in lifestyle and stress. Medical emergencies can put stress on your finances and can become a hassle for your family. One way to manage your finances is to get comprehensive health insurance that will provide you coverage against any medical conditions that may arise.

Today, many companies in India offer health insurance in the form of group health insurance to their employees to get some financial support in case they must spend money on a medical emergency.

What is Group Health Insurance Policy?

A comprehensive health insurance plan that provides coverage to all the members of an organization is called the group health insurance policy. Most of the big private and public organizations in the country provide group health insurance to their employees. Thus, this plan offers the members financial protection in case there is a medical emergency. The premium paid for a group health insurance policy is lower because the risks are divided among all the group members.

How does Group Health Insurance Work?

  • The employer provides the group health insurance plan to their employees
  • The group insurance provides comprehensive covers to the employees at a lower insurance premium
  • The employer decides the coverage that the policy will provide to the members. If the employee does not wish to buy a health insurance plan for the family, he can opt for some top-ups that will increase the policy's coverage.
  • In case a medical emergency takes place, the insured can use the policy at one of the network hospitals of the insurance company
  • For filing the claim, the insured has to submit all the relevant documents
  • After the documents have been verified, the insurance company pays the money directly to the hospital

What is Covered Under the Group Health Insurance Policy?

The extensive coverage that the group health insurance policies provide makes it a popular choice among employers. Some of the conditions that are covered under the group health insurance policy include:

  • Pre-existing conditions without any waiting period
  • Treatment expenses that are spent on chronic illness are covered
  • The health insurance policy can also be extended to the family and dependents of the policyholder
  • Hospital bills for some of the critical illnesses are also brought under consideration
  • Cashless hospitalization at the network hospitals of the insurance company are also included
  • Expenses related to pre-hospitalization and post-hospitalization are also included
  • Ancillary charges are also covered under the policy. These are the charges that are spent on things like medicines, bandages, etc.

Exclusions Under Group Health Insurance:

Generally, Certain conditions are not covered by the group health insurance policy. Thus, these usual exclusions are not accepted by any insurance company. Some of the exclusions under the group health insurance include:

  • Use of life support system in case of any treatment
  • Sex change operation
  • Treatments related to obesity and weight loss
  • Treatment of AIDS and HIV
  • Non-allopathic treatments
  • An injury that is caused intentionally
  • Suicide
  • De-addiction treatment for drugs and alcohol

These exclusions are not the only exclusions that can be there in the policy, so you must check with the individual insurance companies to check what their exclusions are.

Claim Process for Group Health Insurance:

In case of hospitalization or a medical emergency, the claims should be fined as early as possible so that you face no issues. This is the process that you can use for filing claims: 

  • Inform the insurance company about the medical emergency either online or by calling them on their number
  • In case of hospitalization, you must share the details of the group insurance policy with the hospital
  • The insurance company will ask the policyholder for the relevant documents along with the claim form
  • If the claims are verified, the insurance company settles the bill on behalf of the policyholder. 

Documents Required for Claim Process:

This is the list of the documents that you need to file a claim. Different insurance companies may have different requirements, so you have to check that:

  • Claim form with all the relevant information duly filled
  • Medical Reports
  • Discharge Reports
  • Investigation Reports regarding the line of treatment 
  • Prescriptions
  • Hospital Bills and receipts of payment
  • FIR (in case the hospitalization is due to an accident)
  • Other documents requested by the insurance company as per the case

Benefits of Group Health Insurance:

There are many benefits that you can avail yourself of under the group health insurance policy.

These include:

  1. Affordability: The group insurance policy is an excellent option for people who cannot afford an individual health insurance plan. The group health insurance policy premiums are very low, or it is paid by the employers, in some cases.
  2. No Pre-Policy Entry Rules: There are no pre-requisites like medical check-ups for the group members who are getting a group health insurance plan. In contrast, certain individual health insurance plans require the individuals to undergo a medical exam before the policy is issued.
  3. Inclusion of family: Many group health insurance plans allow the policyholder to include their family member in the policy with an added premium. This includes spouse, children, and any dependents that the policyholder may have. 
  4. Standard Coverage: All the members covered under the group health insurance get the same level of coverage irrespective of gender, class, creed, etc. This means that the similar coverage value applies to people of high income as well as low-income groups.
  5. Opportunities for conversion to an individual plan: Some insurer's allow you to convert your group insurance plan into an individual plan if they leave the organization. But you need to pay some amount of conversion fee for this change.

Bottom Line:

With the Covid-19 pandemic and the increase in lifestyle-related diseases, there is a need for health insurance. Group health insurance is one of the best perks that you can get when you join an organization. You should know all the details of the policy so that when the time comes, you can access the policy's benefits. 



1) Which group of medical insurance is the best? 

Ans: Many companies offer group medical health insurance policies, and the best group insurance policy depends upon your requirements. 

2) Can a group health insurance plan be customized?

Ans: Yes, the group health insurance plans can be customized according to the needs of the members of the group. The customization can be done based on designation, salary, etc., and at no extra cost.

3) How many members are needed to purchase a group health insurance policy?

Ans: The number of members required to buy a group health insurance policy differs from insurance company to company.

4) Does the group health insurance policy scheme has any tax benefits for the employees?

Ans:  Yes, the employee can claim the entire amount of premium(up to a certain amount) as tax deduction under Section 80D of the Income Tax Act. But the team member will not get any tax benefits in case the employer pays the entire premium.

5) What is the coverage provided under the group medical insurance? 

Ans: The coverage provided under the group medical insurance differs for different insurance providers. It also depends upon the coverage that the employer requires for his employees.

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