Group health insurance policies offer a variety of benefits covering specific medical expenses, providing valuable financial relief for employees and their families.
But as important are the list of medical expenses covered under a group health insurance policy, so are the exclusions under the policy.
Let’s go over the detailed inclusions and exclusions.
What’s on this page?
Covered Medical Expenses under Group Health Insurance Policy:
- In-Patient Hospitalization: Policies cover hospitalization costs, including room rent, ICU charges, nursing care, and doctor fees. Be mindful of any sub-limits on room rent, as exceeding them may incur additional expenses.
- Pre and Post-Hospitalization Expenses: Costs incurred before and after hospitalization for a defined period are covered, typically ranging from 30 days prior and 60 days post-discharge. Coverage terms may vary, so it’s essential to verify policy details. Also read: How to Negotiate for Billing While in Hospitalization Without Insurance
- Daycare Procedures: Short-stay treatments like chemotherapy and cataract surgery, which don’t require a 24-hour hospital stay, are often included, thanks to advancements in medical technology.
- AYUSH Treatments: Coverage extends to alternative treatments under Ayurveda, Yoga, Unani, Siddha, and Homeopathy, often with certain sub-limits or restrictions.
- Maternity and Newborn Expenses: Some group policies cover maternity expenses, including delivery and prenatal care, along with newborn care for a limited duration post-birth.
- Emergency Ambulance Services: Most policies provide coverage for emergency transport to the nearest hospital during critical health situations.
- Health Check-ups: Many plans offer periodic health check-ups as a preventive care measure, typically once a year, for insured individuals.
- Domiciliary Treatment: Certain policies cover medical treatment at home if hospitalization isn’t possible due to severe conditions or lack of available hospital beds.
Exclusions under Group Health Insurance Policy:
- Pre-Existing Disease Waiting Period: Most policies include a waiting period for pre-existing diseases, often around 2-4 years.
- Cosmetic and Dental Treatments: Unless essential due to accidental injuries, cosmetic and dental procedures are generally excluded.
- Non-Prescription Supplements: Vitamins and dietary supplements, unless part of prescribed post-treatment, are excluded.
- Alternative Therapies Beyond AYUSH: Therapies outside the AYUSH spectrum may not be covered.
- Diagnostic Fees for Non-Hospitalized Cases: Diagnostic tests or health investigations done without subsequent hospitalization are typically not covered.
- Maternity Coverage Limits: Even when covered, maternity benefits often have sub-limits.
- Disease-Specific Exclusions: Certain policies exclude specific diseases entirely, such as congenital conditions, mental disorders, and fertility treatments.
List of Diseases Not Covered under Group Health Insurance Policy
Group policies often specify diseases that are excluded from coverage, including congenital diseases, mental health disorders, and conditions related to infertility treatments. Reviewing these exclusions helps in understanding the limitations of your policy.
FAQ
1. What is the waiting period for pre-existing diseases under a group health insurance policy?
The waiting period varies but typically lasts between 2 to 4 years, depending on the insurer and specific policy terms.
2. Are maternity expenses fully covered under group health insurance?
Maternity expenses may be covered, but many policies include sub-limits, and some benefits apply only after a specific waiting period.
3. Does group health insurance cover all types of alternative treatments?
Most policies cover AYUSH treatments (Ayurveda, Yoga, Unani, Siddha, and Homeopathy) within defined sub-limits, but alternative treatments outside this spectrum may not be covered.
4. Are diagnostic tests covered if there is no subsequent hospitalization?
Generally, diagnostic tests are only covered if they lead to hospitalization. Routine tests or investigations without hospitalization may not be included.
5. Is there coverage for mental health treatments?
Mental health treatments are typically excluded, though some policies may offer limited benefits. It’s advisable to check the policy specifics for mental health-related coverages.
