Comparing Group Health Insurance Plans: How to Choose the Right One for Your Business


Comparing Group Health Insurance Plans: How to Choose the Right One for Your Business

Group health insurance is a customized policy that can be designed per the insured customer’s needs and requirements. Still, the offerings vary from one insurance company to another. For instance, one insurance company might cover the robotic treatments, whereas the others might have it under exclusions. The basic covers such as sum insured, in-patient/out-patient/daycare hospitalization cover, alternative treatments, domiciliary hospitalization, etc., are similar, with certain variations to be examined before purchasing a group health insurance policy.

For this purpose, one needs to compare the different group health insurance plans offered by the insurance companies and then make the purchase decision. Comparison can lead to better output, mainly in the case of the group health insurance policy. The group health insurance policy must be compared to ensure it suits their business needs. For comparison, it is better to take the help of an insurance broker such as Ethika Insurance Broking, who have scaled their customer base from 1 to more than 450 within a few years mainly due to the valuable service being offered to their customers.

Here are the Key Factors in Selecting the Ideal Group Health Insurance Plan


The most important thing to consider while purchasing a group health insurance plan is the premium charged by the insurance company. Insurance companies would charge the premium and reduce it based on the negotiation skills of the customer. If the customer is smart and strong enough to negotiate, one can get high discounts on the group health insurance premium. More than simply comparing premiums from different insurance companies would be required, as the coverage would differ from one company to another. To overcome this problem, one should get quotes from all the available insurance companies and then make an apple-to-apple comparison. If this is not feasible, employing an insurance broker to compare on your behalf is better. Insurance brokers have negotiation skills and knowledge of different insurance products, which would ultimately benefit their customers.

The premium under the group health insurance policy can be reduced considerably and is possible only if the negotiations are done properly with the insurance company. The higher the number of members, the higher the negotiation power, as insurance companies would get the premium in bulk and would not prefer to lose out on such business. The premium is usually reduced by getting comparative quotations from different insurance companies in the market.

Claim Settlement Ratio

The other important thing to check before choosing the group health insurance policy is to check for the claim settlement ratio of the insurance company. Claim settlement ratio is the number of claims settled by the company to the number of claims received during a particular period of time. The higher the claim settlement ratio, the higher the chance of claim settlement. In addition to this, the Incurred claim ratio should also be checked before deciding on the insurance company. The incurred claim ratio is the net amount (premium) of claims settled to the net premium collected during a policy period. The higher the incurred claim ratio, the higher the chance the company makes losses as it settles higher collected amounts. This could be due to the bad underwriting practices employed by the company, sudden big losses such as pandemics or epidemics, etc. The claim settlement ratio or the claim settlement intention of the insurance company can be known from the market and the insurance intermediaries associated with a particular company. The other thing to note is the quantum of claim settlement that the insurance company is doing. Some insurance companies might settle the claims partially but close the claim to increase the claim settlement ratio. Going with an experienced broker who could settle all your claims without much hassle is advisable.

Network Hospitals

The other important thing to consider while comparing the group health insurance plans is to check for the network hospitals available in your place of residence or your city. Network hospitals are tied up with the insurance company to provide cashless claim settlement facilities to the insured customers. Network hospitals would be concentrated mostly in Tier 1 cities with adequate numbers of hospitals. It is important to check if there are enough network hospitals in your area and other areas where your employees and offices are present. It would not be possible for employees to go to a nearby city every time they need to undergo treatment in a network hospital. So, checking the number of network hospitals in your area is important before finalizing the group health insurance policy. Customers even have the option to request the insurance company to enroll a particular hospital as a network hospital if it is their preferred hospital. In addition to the network hospitals, there are preferred network hospitals (PPN), known as preferred partner network hospitals, which are a subset of the network hospitals. The insurance companies prefer these hospitals and customers taking treatment in these would get extra benefits such as discounts on the bills and other add-on benefits during their treatment.

Customer Experience

The other important factor to compare is the customer’s experience. Suppose a particular insurance company’s group health insurance customers are not satisfied. In that case, avoiding going with that company is advisable as the same experience might be repeated with you shortly. Customer experience can be known from all social media platforms these days and even from the intermediaries of the company. Customer experience includes various elements such as after-sales service, endorsement support, additions and deletions in the policy, claim settlement support, cashless, and reimbursement. Various items must be considered to measure the customer experience in the group health insurance market. Higher customer experience leads to renewal with the same insurance company. One can check the renewal ratio of the insurance company to understand the services offered by the company. The same should also be considered while selecting the insurance broker for your group health insurance requirements. Insurance brokers such as Ethika Insurance have the highest customer retention ratio in the market, which is only possible due to their impeccable service. Insurance brokers can get the required service from the insurance company if there is any deficiency in the service provided by the insurance company.

TPA/ In-house

The other thing to be compared is who is the group health insurance policy servicing? Third-party administrator (TPA) or an in-house team of the insurance company. The two have many differences, and it is important to understand which one suits your requirements. TPAs mediate between the insurance company and the customer at the time of claim settlement. TPAs would also help the customers with endorsement-related issues and distribution of health cards, etc. At the time of hospitalization, insured customers can directly contact the TPA, who would, in turn, contact the insurance company to provide authorization for a cashless claim settlement facility. Once the TPA receives the cashless approval from the insurance company, it will provide the cashless authorization letter to the hospital to carry out the treatment. The TPA would settle the claim with the hospital and later claim from the insurance company. In the case of in-house, all the activities mentioned above would be taken care of by the insurance company’s team. They would provide the cashless claim settlement approval and settle the claim amount with the hospital directly. Each has advantages and disadvantages depending on your requirements and the insurance company.

Hidden Exclusions

Exclusions in a group health insurance policy are those treatments that are not covered under the policy. Permanent exclusions are those which are present in the policy as a rule from the IRDA or policy design whereas insurance companies can add certain exclusions under the policy. These exclusions are generally hidden by the insurance companies in the quote sheet and would also be reflected in the policy document. These exclusions include robotic treatments in certain hospitals, bariatric treatments, etc. Hidden exclusions would become visible only at the time of claim settlement, and it would be very difficult for the customer to get the claim settled as it would not come in the scope of coverage. One has to check for the hidden exclusions in the quote sheet before purchasing the policy and also check the policy document for any hidden exclusions that were not present in the quote sheet but appeared in the policy document. Hidden exclusions could be the co-payment or sub-limits under the group health insurance policy. Other exclusions, such as co-payment in case of reimbursement claim settlement availed when the treatment is taken in a network hospital, are common for most insurance companies and are included to prevent the customers from committing fraud.

Coverage/ Sum Insured Options

The other important thing to compare while taking the group health insurance policy is the coverage or the sum insured options available under the policy. The sum insured usually ranges from Rs.50k to Rs.15 Lakhs, and the insurance company should separately underwrite anything above this. It is rare to find Rs.1 Crore sum insured in a group health insurance policy that is pre-underwritten. The policy can be either on an individual sum insured basis or on a family floater basis, which is to be decided by the insured customer. Family floater sum insured floats among the family members and can be utilized by anyone without any restrictions, whereas the individual sum insured is restricted to each member and cannot be utilized by another member of the same family. It is to be noted that the individual sum insured policy would be costly when compared to the family floater one due to the increase in the overall sum insured in the policy. The other advantage of the group health insurance policy is the differential sum insured options for different members, i.e., top management can take a higher sum insured, followed by middle and lower management. Different sum-insured options are available in a single group health insurance policy, making it easier to cover the requirements of different people.

Flexibility for Endorsements

Endorsements are changes in the terms and conditions of the insurance company’s policy. Endorsements could be monetary as well as non-monetary. Monetary endorsements usually change the scope and coverage under the policy. Monetary endorsements include adding or deleting members from the policy, adding the sum insured, increasing the scope of coverage, etc. Group health insurance policy should provide the required flexibility for the endorsements. One should be able to carry out the endorsements effectively without having to wait for a longer period of time. Insurance companies have created a cash deposit account to facilitate smoother endorsements in which the insured customer needs to maintain a sufficient balance. In case of additions, the endorsement would be carried out immediately after receiving the intimation, subject to the required balance being available in the cash deposit account. In contrast, the pro-rata refund would be processed into the cash deposit account in case of deletions. This flexibility for endorsements ensures that all the members are adequately covered within a particular timeframe.

Group Health Insurance Software Compatibility

Group health insurance involves additions and deletions of the members during the policy period. Additions usually happen as new employees join or there are certain life events such as marriage or childbirth for the existing employees. Deletions occur when an employee leaves or is superannuated from the company. This would be an ongoing process in the organization for which manpower support and a high level of coordination are required. To ensure smooth coordination, Ethika Insurance has launched Group health insurance software, which would connect the insurance company portal with the customer. With this group, health insurance policyholders can easily change their policies. Additions or deletions can be directly entered into the software, which would be updated in real-time based on the balance in the cash deposit account. The endorsement certificates, as well as the health cards, can be generated using the group health insurance software. The software is easy to operate and reduces the confusion of adding or missing out on the employees.

Cashless Approval TAT

The other important thing to consider while comparing the group health insurance plans is the check for the turnaround time required for the cashless claim settlement approval that the insurance company would give. Many insurance companies promise to provide cashless approval within 2 hours of intimation, but the ground scenario might differ. So, it is also advisable to talk to the hospital staff regarding the TAT taken by the insurance company for giving the cashless claim settlement approval. Once the cashless approval is given, only the hospital would start the treatment except in case of emergencies. So, checking the TAT for cashless approval is important, as an emergency can happen anytime. Insurance companies should have enough staff to provide seamless service for cashless approval, even if the approval request is made during odd hours.

For more information on the group health insurance plans, please book a call with our health insurance experts at Ethika Insurance Broking.

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Susheel Agarwal

Namaste. I'm Abhinay Nedunuru, a Fellow of the Insurance Institute of India with a passion to make insurance simple and crisp. I write on insurance and investment. I have a passion for teaching and training in particular to insurance. I'm currently doing my PhD from IIM in Management.