A Group Mediclaim Policy is health insurance provided by a company to its employees. It functions similarly to an individual healthcare plan, with a few exceptions, one of which is that employees pay no premiums.
In India, following COVID-19, the insurance regulator, IRDAI, issued a circular on April 1, 2020, requiring all registered organisations to provide medical coverage to their employees as a regular operating procedure for work resumption.
Although group health insurance is not a new concept, many employees have difficulties comprehending it. Here is our guide to help you gain clarity on it.
The key benefits of this plan are detailed below.
1. Zero Premium Burden
The employer pays the premiums for the Group Mediclaim Policy, and employees do not have to pay anything out of pocket. However, suppose a group of employees wishes to extend the coverage benefit by requesting add-ons or to include their dependent parents in the policy. In that case, the company may request that the employees split the costs.
2. No Medical Screening
If someone wants an individual health plan, they must first undergo a medical examination. If diagnosed with a pre-existing condition, the insurer will deny coverage or charge them a higher premium. However, group cover is available without any medical test.
3. No Waiting Period
When your employee purchases an individual health plan, they cannot use it immediately, even if admitted to the hospital for conditions covered by the policy agreement. That is because individual or family floater plans include waiting periods ranging from 30 days to many months, depending on the condition. However, with group health insurance, employees can be reimbursed for treatment even if they become ill on the first day of employment.
Some common expenses this plan covers are:
- Pre-existing diseases
- Ambulance charges
- Pre-hospitalisation expenses
- Hospitalisation charges
- Post-hospitalisation expenses
- ICU charges
- Room rent
- Pharmacy bills
- Coverage for personal accidents
- Chronic diseases
- Medical screening expenses
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Suppose you own an investment advisory firm, and Ravi is a senior salesperson in your office. Ravi had diabetes before joining your organisation. However, his condition was never a hindrance to accomplishing the assigned duty. However, one day, while driving home after office hours, his blood sugar levels shot up, and he suffered a heart attack that necessitated emergent ICU admission.
The samaritans on the road assisted Ravi and drove him to one of the best nearby hospitals. The hospital handed a bill of Rs 75,000 in treatment charges to Ravi’s family members.
In this case, he or his family members will not be required to pay for any treatment costs if the treatment is provided at network hospitals. That is because the Group Mediclaim Policy you purchased will cover the expenses regardless of whether he has a pre-existing condition or the occurrence of a medical crisis while he was not performing his official duties.
If the hospital where he was treated had no agreement with the insurer, Ravi would have to pay out of pocket. Next, he has to submit the invoice through the proper channel to receive reimbursement.
The following documents are necessary for raising claims for a Group Mediclaim Policy.
- Claim form available on insurer’s website or their branch
- A recommendation letter from a certified doctor stating that admission to the hospital is necessary
- A discharge letter issued by the hospital
- Medical investigation report
- Original invoices outlining treatment costs with hospital stamp
- FIR (applicable in the case of a road mishap)
- Cancelled cheque of the account where the employee wants to receive the reimbursement payout
Here are the necessary steps for a successful claim settlement.
- The employee must notify the insurer of the hospitalisation within 48 hours of admission.
- The TPA (third-party administrator) assigns a claim number so the employee can readily track its status.
- The employee must then pay and have the original invoice available.
- The insurer may request additional information related to the treatment procedure.
- If approved, the claim will be initiated, and the amount will get credited to the insured employee’s bank within three to four working days.
Understanding the Group Mediclaim Policy is simple. When an employee joins the organisation, the company’s HR department provides a policy document that clearly explains the inclusions and exclusions, the claim process, and any other critical clauses determining when the policy can be used. Read the document carefully and seek clarification to clear all doubts.