What to Look for in a Group Health Insurance Provider: Key Features and Benefits


What to Look for in a Group Health Insurance Provider- Key Features and Benefits

Group health insurance is very important for businesses, and one should be careful and mindful while selecting the provider for group health insurance. All insurance companies offer group health insurance, which one can take directly from them or through an intermediary. It is important to consider certain things before selecting the group health insurance provider, as you cannot change the provider during the policy period.

To prevent such hassle, one should look for important things in a group health insurance provider such as network hospitals, hidden exclusions in the group health policy, value-added benefits, if any, the insurer’s reputation in the market, time taken for cashless approval, whether the provider is competitive in the given market and the service if offered through TPA or in-house.

Here are the things to look out for while selecting the group health insurance provider:

Network hospitals:

Network hospitals are those tied up with companies that provide cashless claim settlement facilities to health facility policyholders. Insured customers need not pay hospital bills after availing treatment from any cashless hospitals subject to the terms and conditions, such as the limit being the sum insured under the policy and any excess amount mentioned under the policy which had to be borne by the insured.

The list of network hospitals would be available with the insurance company, and one should check the list before taking the group health insurance policy. There must be enough network hospitals in all the employees’ locations. For example, if your organisation has branches in more than 1 location, you need to ensure enough network hospitals in every location your organisation is present.

This is to be considered seriously as the number of network hospitals would vary from one city to another and one insurance provider to another. For instance, we could find more network hospitals in Metro cities, state capitals and Tier 1 cities when compared with Tier 2/3 cities due to the limited number of hospitals in such areas and the limited bargaining capacity of the insurance companies.

In Tier 2 and 3 cities, there would be fewer hospitals catering to the needs of people, and many of them might not agree to join as network hospitals as joining as network hospitals would mean that they had to agree to packages for every treatment, which would cost less than what they charge without the package.

Hidden Exclusions:

The thing to look out for while finalizing the group health insurance provider is hidden exclusions in the policy. The policy could have hidden exclusions, such as sub-limits, copayments, or deductibles. These hidden exclusions would differ for different insurers based on their underwriting guidelines.

For instance, one provider may require senior citizens to compulsorily pay a 20% copayment for every group health insurance plan claim. Another provider may put sub-limits for pre-existing conditions for senior citizens. The hidden exclusions include deductibles or sub-limits for robotic treatments. T

he hidden exclusions are usually mentioned in the terms and conditions while quoting for the group health insurance policy. Still, the customers often overlook them as they usually listen to the intermediaries and depend on their words while taking the policy.

For this reason, one should select their insurance intermediary carefully before selecting the group health insurance provider. Insurance brokers are considered resourceful regarding group health insurance plans among the insurance intermediaries.

Insurance brokers such as Ethika Insurance Broking have over a decade of experience providing group health insurance solutions to customers. Insurance brokers would be well versed with the conditions of the group health insurance plans and can explain the same to their customers by helping them make informed decisions.

Value Added Benefits:

Group health insurance often comes with value-added benefits such as wellness benefits, reward points for maintaining a healthy lifestyle, arranging health checkup camps, etc. The insurance intermediaries usually offer value-added benefits to their customers from their end; the insurer has no role in these offerings.

So, while selecting the group health insurance provider, one should take advantage of value-added benefits from insurance intermediaries. Among the insurance intermediaries, only the insurance brokers have the resources to arrange such wellness benefits for their customers.

For instance, Ethika Insurance Broking offers red carpet claim assistance to process the claims with little intervention from the employee’s side, employee happiness programs to increase employees’ happiness levels, thereby increasing productivity, and employee engagement programs to engage the employees in their daily activities without affecting productivity.

Value-added companies do not offer value-added benefits in most cases. Still, they would be offered to their customers’ insurance broking companies, so it is important to consider the intermediary while taking the group health insurance policy before deciding on the group health insurance provider.

Reputation in the market:

The other thing to consider is the reputation of the group health insurance provider in the local market. There are instances where the insurer has denied the members’ claims without valid reasons and a few cases where the claims are under-settled.

For example, an insurance company has denied most of the claims under the group health insurance plan to maintain its claim loss ratio without giving a valid reason to the insured or has reduced the claim amount under each claim, stating various reasons to reduce the increasing loss ratio.

In such cases, the reputation of the insurer would be damaged, and word of mouth could spread their actions in the local market. One should find out the behavior of the insurance companies towards their group health insurance customers before making purchase decisions.

The after-claims service of the insurance company also plays an important role in deciding the group health insurance purchase. It is also possible that the insurance company’s service depends on its employees and their willingness to go the extra mile to settle the insured’s claim. Therefore, having a good relationship with the insurance intermediaries who can settle the claim on your behalf is important.

Cashless approval time:

Cashless approval is the time taken to provide cashless approval to the network hospital. When you go to a network hospital for cashless treatment, the insurance desk contacts your insurance company for cashless approval.

Once the approval is received, the treatment will start from the hospital’s end. The authority to provide cashless approval rests with the insurance company, and the turnaround time (TAT) varies from one insurance company to another.

Some insurance companies promise to provide cashless approvals within 30 minutes, whereas some take up to 4 hours to process the request. The advantage is that cashless approval is not required to start the treatment in case of an emergency.

Hospitals would start the treatment without waiting for approval but ask the customers to pay the bills if cashless approval is not required. Therefore, checking for the cashless approval time claimed by the insurance company before purchasing the group health insurance policy is important.

Competitive premium:

The most important thing to consider while looking for a group health insurance provider is their premium. While most insurance companies offer group health insurance plans, only a few can offer competitive premiums.

One can approach the insurance company directly or go through an insurance intermediary. In the case of a group health insurance policy, it would be difficult for you to go to every insurance company personally and collect the quotes.

Therefore, you would approach an insurance intermediary who could source the quotations on your behalf. Even among the insurance intermediaries, only the insurance brokers can offer quotes from any number of insurance companies as they do not have any restriction on the number of insurers they can tie up with.

Insurance brokers have the strength to negotiate with insurance companies on premiums, offering discounted premiums to their customers. So, while selecting the group health insurance provider, one should consider the insurance broker to get competitive premiums.

TPA or In-house:

Third party administrators coordinate the activities among the insurance company, the insured, and the network hospital. TPAs are known to be handy for claim settlement as they take care of the claim settlement process to make it seamless.

Some insurance companies get help from TPAs to manage their claim-related activities, whereas some companies have in-house facilities that do the work of TPAs. There are advantages and disadvantages of TPA and In-house claim settlement, which can be found here.

You should be able to decide between the TPA and In-house, as each has merits and demerits. TPAs mainly focus on the claim settlement process and also help in endorsements. Insurance brokers such as Ethka Insurance have made the work of TPAs easier by providing Group Insurance software that can be linked with the organisation’s and insurance company’s Employee benefits portal, thereby providing real-time additions and deletions and claim settlement updates in the portal.

So, things such as the competitiveness in premium, time taken to provide cashless approvals, reputation in the market, list of network hospitals, value-added benefits, hidden exclusions and TPA or in-house claim settlement facility should be considered before deciding on the group health insurance provider. For more information on the factors to consider while deciding the group health insurance provider, please book a call with Ethika Insurance Broking to talk with our group health insurance experts.

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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.