How to evaluate your group medical insurance cover?
You run a small company and, to support your staff, you offer group health coverage. However, one day you came to know about an employee's illness that required immediate hospitalisation. At the time of discharge, the employee had to pay the major portion of the bill, and the insurer covered only minimal expenses. You suddenly realise that while you provide health benefits, you are not fully sure if the policy truly meets your employees' needs. This moment pushes you to evaluate whether you have bought the correct policy.
Things to check in a group medical plan
Before you buy a group medical insurance policy, it is recommended to check the following parameters to avoid surprises at the last moment.
Cost comparison
Before you purchase a plan, thoroughly evaluate the cost-to-benefit ratio with multiple insurers. Check the list of illnesses they cover and the additional clauses applicable to the covered diseases. Also, review the list of exclusions.
Once clear on coverage, compare add-ons. There are certain diseases or expenses that some insurers may cover under their base plan, while others may require you to purchase a separate add-on for them. You must also read online reviews to find out if there are any hidden clauses or charges that the insurer does not communicate.
Check the network hospital
A network hospital in group health insurance refers to a healthcare facility that has a tie-up with the insurer to offer cashless treatment. This means your employees do not have to pay anything up to the sum insured amount during the course of treatment at the hospital. However, anything beyond the sum insured or covered expenses must be borne by the employees.
When assessing network hospitals, make sure the insurer has tie-ups with healthcare facilities in the city where your office is located. If not, during a medical crisis, your employees would have no option but to go for reimbursement.
Claim settlement
Claim handling should be your top priority. Review the claim process steps: are they easy, online, and quick? Visit the IRDA website to review and compare the claim settlement ratio. It gives insight into how many claims the insurer received in a policy year and how many they settled.
You must also read online reviews to check if the support executives are available 24/7. Also, check the common list of documents they ask for. Most importantly, check the pre-authorisation process and its turnaround time.
Check the room rent limit
Before buying coverage, check the room rent limit. It is the maximum amount the insurer will pay per day for a hospital room. Room rent limits can be a fixed amount or a percentage of the sum insured. If your employee chooses the room above the threshold limit, the proportionate deduction rule applies.
This means the insurer reduces all hospital expenses, including consultation fees, ICU expenses, and nursing charges, in the same ratio as the allowed room rent compared to the actual room rent.
For example, if the room rent limit is ₹5,000 and your employee chose a room costing ₹10,000. That means the 50% proportionate deduction rule applies here. If the total bill is ₹2,00,000, the insurer will only pay 50%, that is ₹1,00,000.
Newborn cover
If most of your employees are in the age group of 25-35, having group health insurance that covers newborns and maternity can be handy. Maternity coverage includes expenses related to prenatal check-ups, doctor consultations, diagnostic tests, hospitalisation for delivery (normal or C-section), medicines, and postnatal care.
Newborn cover takes care of NICU expenses, vaccination costs, and any medical conditions arising after birth. However, congenital diseases are subject to policy exclusions.
Additional benefits
Always look beyond basic hospitalisation cover. Check if the insurer you are finalising offers wellness benefits. These can include free health check-ups that help employees detect illnesses early and take steps to get them treated before they become life-threatening.
You must also check if the plan includes fitness or wellness programmes such as gym memberships, yoga sessions, mental health counselling, stress management workshops, and nutrition guidance. If the insurer covers teleconsultations with registered doctors, managing health becomes easy.
Customisation benefits
Customisation matters, especially if your firm employs a large number of employees with different lifestyles and health needs. Check if the insurer offers flexibility in choosing the sum insured. See if you can add or remove benefits such as maternity cover, OPD, wellness programmes, or critical illness.
When it comes to customisation, what's more important is to confirm with the insurer if there is a provision to add or remove an employee mid-term.
Conclusion
Buying a group insurance health cover does not mean getting the cheapest plan available in the market, but investing in one that offers comprehensive coverage while being affordable. To select the best policy, it is recommended to check the network hospitals, claim handling, room rent limit, newborn cover, and customisation features. You must also review whether the insurer offers wellness benefits to help your employees manage workplace stress.
