Group Health Insurance covers the medical expenses of the insured members up to the sum insured mentioned under the plan in return for a premium amount that the insured customer pays. Group health insurance can be classified as employee-employer and non-employee-employer. Most group health insurance plans belong to the employee-employer segment, where the employer would take the group health insurance policy for employees. In the case of non-employee-employer policies, a group of people would avail of the group health insurance plan. In employee-employer relation health insurance plans, three types can be based on the premium-sharing agreement. If the employer entirely contributes the premium, then the terms and conditions of the policy would be decided solely by the employer. If the premium is shared as per a pre-agreed proportion between the employer and employee, then the terms and conditions would be agreed upon mutually between the employee and the employer. If the employees contribute the premium, the terms and conditions would be stated only by the employees. Non-employee-employer groups and health insurance plans do not have the employer-employee relationship. The employees form a group to avail health insurance such as associations, NGOs etc.
Be it an employee-employer relationship or a non-employee-employer relationship.
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It is important for everyone to follow the below tips for choosing the right group health insurance plan:
Adequate Sum Insured:
The main thing to consider while choosing a group health insurance plan is the sum insured under the plan. One should make sure that an adequate sum insured is opted for while taking the group health insurance plan. Too high or too low sum insured would lead to issues, high sum insured comes with high costs, whereas low sum insured comes with low coverage in times of emergency. The employer or the employees should decide the adequate sum insured before taking the group health insurance plan. The definition of the adequate sum insured could be different for different people. The sum insured in a group health insurance policy is the insurer’s maximum liability during the policy period. If the claim amount exceeds the sum insured, one can utilize the corporate buffer sum insured or super top-up policy. Employers can avail of different sum insured options for different employees in the organization. In different general slabs of sum insured would be taken for different grades of employees such as top management would be insured for a high sum followed by middle management and then lower management. The premium would change according to the sum insured under the policy. The higher the sum insured, the higher would be the group health insurance premium.
Network Hospitals:
The other important tip before purchasing the group health insurance policy is to check the number of network hospitals all over India and in your locality. For example, if you are based out of a tier 2 city and all your employees reside in this tier 2 city, then there must be a required number of network hospitals in this tier 2 city. If the insurance company has the highest number of network hospitals in India but very few hospitals in your locality, then it would be illogical to opt for that insurance company. Network hospitals offer a cashless settlement of claims for customers of insurance companies. Insurance companies contract with hospitals to provide cashless claim settlement facilities to their customers and fix packages for different treatments. Customers availing of in-patient/daycare/ out patient hospitalization treatment from any network hospital would be eligible for a cashless claim settlement facility. If a customer wants a reimbursement facility in a cashless network hospital, the insurance company will apply a co-payment in the claim settlement process.
Group Health Insurance Software:
A group health insurance policy requires continuous modifications, i.e. additions in case of new employee joining or on the occurrence of certain events such as marriage or childbirth and deletions in case of employees leaving or retiring from the organization. In both cases, the insured customer needs to inform the insurance company regarding the changes to the insurance policy through endorsements. In case of additions, an extra premium is to be paid, whereas, in deletions, the premium would be refunded. In both cases, the premium would be on a pro-rata basis. In the case of a large organization, it would be difficult to send the data continuously to the insurance company for additions and deletions every time an employee joins. Also, it would be difficult to maintain the endorsements. To address this issue, insurance broking company Ethika has launched a group health insurance software that could be linked with the insured customer’s database. Whenever an addition or deletion is made in the policy, the insured customer or the employer can enter the details in the portal provided by Ethika insurance broking. The rest would be taken care of by Ethika Insurance. For this to happen, the insured customer should maintain a Cash Deposit account with the insurance broker and maintain the minimum balance. This account helps cover the new members in the group insurance policy. Newly joined members can be covered from day 1 if the account has sufficient balance. Section 64VB of the Insurance Act permits the insurers to provide coverage only after receiving the premium.
Value Added Services:
The other tip to be followed while choosing the right group health insurance plan is to check for the value-added services offered by the insurance company or intermediary. Value-added services include fast-track claims settlement process, group health insurance software, wellness services such as employee happiness programs, employee engagement programs etc. Value-added services include regular health checkups such as eye checkups, blood donation camps, etc. These value-added services must be considered while planning for the group health insurance policy, as these are available free of cost from the insurance company or intermediary. Generally, only insurance brokers provide value-added services to their group health insurance customers. The major advantage of availing group health insurance plans from an insurance broker is that they can provide value-added services at no extra cost when compared to other insurance intermediaries who would be charging for these services. Value-added services would also bring the effective premium paid under the group health insurance policy.
No Co-payment/Sub-limits:
The most important tip to follow while selecting the group health insurance plan is to check for any co-payments or sub-limits under the policy. A co-payment is an amount that has to be borne by the insured customer at the time of claim settlement. In simple terms, the insured customer is made for sharing the liability during claim settlement. Sub-limits are the limits set under the existing sum insured for a group health insurance plan. For certain diseases, the insurance company would set a limit below the sum insured limit, known as sub-limits. A co-payment or sub-limit is intended to reduce the claim amount so that the overall outgo is reduced for the insured customer. A group health insurance plan should be free of a co-payment or sub-limit as it would hinder the main purpose of availing a group health insurance plan. One should go for plans with no co-payments and sub-limits to extract maximum benefits from the group health insurance plan. Co-payment and sub-limits could reduce the overall premium payable under a group health insurance plan to a certain extent. Still, the essence of taking a health insurance policy would be lost as the co-payment would be applicable for each and every claim made during the policy period.
Waiting Periods:
Plans for group health insurance can be tailored to suit the requirements and needs of the insured. Waiting periods are when the insurance company would not pay the claims arising out of certain conditions for which the waiting period is applicable. The pre-existing waiting period, specific disease waiting period, initial waiting period, maternity waiting period, disease-specific additional waiting period etc. Insurance companies may decide to introduce a particular waiting period for a specific disease if it believes that considerable claims could arise from that disease in the future. The waiting periods usually range from 30 days to 4 years in most insurance policies. The claim that is made in the time of waiting would not be covered by the health insurance plan for group members. It is important to note that waiting periods are not mandatory in a group health insurance policy. So if one chooses to opt for waiting periods, one can avail of a reduction in the premium payable. Still, the basic essence of availing a group health insurance policy would be lost. Unlike a retail health insurance plan, the major advantage of a group health insurance policy is that one can claim without having to wait for a certain period of time.
Demographics of Employees:
The employees’ demographics also should be considered while deciding on the group health insurance plan. The location of the employees plays an important role, as there must be enough network hospitals in these locations. For example, if you have an organization spread in various cities in India with offices even in Tier 3 locations, then it would be important for you to check for the network hospitals in these locations so that your employees can avail of a cashless claim settlement facility. It would only be possible for some of your employees to travel to a nearby city to avail cashless claim settlement facility every time they fall sick. So one should consider the location of employees and check for the network hospitals in these locations before choosing the group health insurance plan. The age of the employees should also be considered before taking the group health insurance as young employees may have less chance of falling sick compared to the old employees. The family members of the employees included in the group health insurance policy would also play an important role in deciding the group health insurance.
Harmonious Claim Settlement:
The other important tip to consider while choosing the group health insurance plan is the claim settlement facility offered by the insurance company. Claim settlement can be either through cashless or reimbursement basis. Claim settlement plays an important role in group health insurance as it is the main element in the process. If the claim settlement is unsatisfactory, then there is no point in taking the group health insurance from that insurer. Before purchasing the group health insurance policy, one should check the insurance company’s after-claims service and claim settlement ratio. The major thing in the cashless claim settlement facility is the time taken to provide cashless approval. There are insurance companies which claim to provide the cashless claim settlement approval within 30 minutes depending on various factors such as the type of illness, location of the hospital etc. Claim settlement also depends on the kind of insurance intermediary. Insurance brokers provide the highest claim settlement services.
Robotic Treatments:
The other important thing to consider while choosing a group health insurance policy is the coverage for advanced treatments. Due to the advent of technology, many treatments are being performed by robots which would increase precision and reduce human errors. But due to the need for more data on the success of these robots, insurance companies generally prefer not to cover the operations they perform. One should check for the robot coverage and the sub-limits under the group health insurance plans. Robotic treatments can be seen in various fields, such as eye surgeries, brain surgery, certain cancer therapies etc. The insurance regulator and development authority in India 2019 issued a mandate for insurance companies to pay for robotic therapies. Robotic surgery expenses include hospitalization, surgeon or doctor fees, nursing charges, ICU or room rent, and pre and post-hospitalization expenses. Robotic surgeries are performed only when a qualified surgeon recommends a robotic surgery. There could be a waiting period for robotic treatments under the group health insurance plans, which must be checked before taking the policy.
Compare and Buy:
The other tip for choosing the right group health insurance plan is to compare different insurance companies and make the purchase decision. Insurance brokers such as Ethika Insurance have tied up with almost all the insurance companies offering group health insurance plans. One can compare the group health insurance quotes from different insurance companies and make the purchase decision. To know more about the group health insurance plans offered by Ethika insurance broking, please visit the page and discuss with our health insurance expert.
