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Group Health Insurance Exclusions – List of Things Not Covered for Employees


Summary

Group Health Insurance

Group health insurance compensates the hospitalization and other related expenses of the insured members up to the limit mentioned under the policy terms and conditions in return for an amount known as premium. The premium under the group health insurance policy is mostly paid by the employer and employee gets to avail of the health insurance cover.

Group health insurance can be given for employee- employer Relationship as well as non-employee-employer relationship also. Non-employee relations can be seen in the case of association’s, NGOs, etc. Employee employer Relationship can be seen in any organization.

The group health insurance policy taken by an organization to cover their employees can also be extended to include the family members of the employee. The terms and conditions of the policy would be decided by the employer and the employee would have a minimal say in deciding the terms and conditions under the policy.

Group health insurance policy is basically a master health insurance policy which contains the details of all the members covered under the policy and each member would be given a health card which contains the details of the members insured.

The health card acts as proof of insurance in case of hospitalization due to any illness or disease or accident.

Group health insurance, also known as group medical insurance, is valid for a period of one year and can be renewed with the same insurance company or a different insurance company. Health insurance for employees can be availed in the form of employee health insurance under a single policy instead of taking multiple health insurance policies.

Let us understand the General Exclusions under Group Health Insurance:

a. Pre existing conditions: Pre-existing conditions are the diseases or illnesses that exist prior to taking the health insurance policy. For example, if you have diabetes or High blood pressure before the inception of a health insurance policy and it was declared in the proposal form at the time of purchasing the policy, it would be considered as pre-existing condition and any claim arising or attributable to it would not be paid by the insurance company for a certain period of time.

This period of time is known as the pre-existing condition waiting period during which the customer has to pay the hospitalization expenses on his own.

These pre-existing conditions would not be covered under a health insurance policy unless specifically requested by the customer. Group health insurance policy doesn’t cover the pre-existing conditions in the basic policy. This would instead be covered under the additional cover on payment of the additional premium.

b. Alternative therapies: Alternative therapies such as Acupressure, Naturopathy, Magnetic therapy and such would not be covered under the group health insurance policy unless and until specified and clearly mentioned in the policy. The coverage for alternative therapies would not be fixed among the insurance companies as some insurance companies would cover them as an exception with certain limits whereas few other insurance companies would altogether reject the proposal to cover the alternative therapies.

Ayurveda, Yoga, Unani, Siddha and Homeopathy would also come under alternative treatments which are usually covered by all the insurance companies in India without any special requests for coverage. Even though these treatments are covered, the limit of coverage under these treatments would differ from one Insurance company to another.

Few Insurance companies limit the coverage to alternative treatments such as Ayush to a certain percentage of the sum insured whereas few other companies pay the claim amount up to the entire sum insured mentioned under the policy.

c. Diagnostic expenses: The diagnostic expenses such as blood tests, scans, pathological tests etc would not be covered under the group health insurance policy unless they are done as a part of the hospitalization necessitated during the treatment.

For instance, infertility treatment requires diagnostic expenses which would not be covered under the group health insurance policy but the MRI scan taken at the time of hospitalization due to an accident would be covered under the group health insurance policy.

These diagnostic expenses would not be considered unless they are payable under the hospitalization of the policy.

d. Suicide attempt: The group health insurance would not cover the expenses arising out of treatment as a result of suicide or attempted suicide. These injuries can be self inflicted or suicide attempt related which would not be covered under the group health insurance policy. For example, if a person commits suicide by jumping into a river but is saved by some people and admitted to a hospital, then the medical expenses incurred in the hospital would not be covered by his employee health insurance policy.

d. War or Allied activities: Expenses incurred due to war and allied activities would not be covered under the group Mediclaim insurance policy. Expenses incurred by an employee due to war or war like situation would not be covered by his health insurance for employees policy as the policy clearly excludes the expenses incurred due to war and allied activities.

War and allied activities would be a permanent exclusion under the group health insurance policy and many companies would not prefer to insure the companies in a war-inflicted country.

e. Cosmetic treatments: Cosmetic treatments are those that are done to increase one’s beauty. Cosmetic treatments such as plastic surgery, dental surgery, eye surgery, or any other such surgeries would not be covered under the group Mediclaim insurance policy. Cosmetic treatments are viewed as a means of increasing one’s beauty and is a deliberate or willing act committed. Insurance would not cover the deliberate acts as it would only cover unfortunate events.

Cosmetic treatments would be covered in case of accidents or any other injuries or illnesses. For instance, if you meet with an accident and require facial cosmetic surgery to restore your face to its original condition, then the group mediclaim insurance policy would cover the expenses.

f. Pregnancy and related conditions: The group health insurance policy would not cover the conditions and expenses arising out of pregnancy and related conditions. For instance, the admission of a patient to the hospital due to pregnancy-related issues would not be covered by the group health insurance policy.

The policy covers maternity and childbirth but not the complications arising out of childbirth or pregnancy.  Certain insurance companies cover the abortion or termination of pregnancy on a doctor’s advice.

There would be a section for maternity Expenses under the group health insurance policy where the customer has the option to choose the sum insured under the policy. The maternity sum insured would be in addition to the basic sum insured under the group health insurance policy.

Pregnancy and related conditions are not covered under the group health insurance policy unless and until mentioned in the terms and conditions of the policy.  Infertility expenses would also not be covered under the group health insurance policy.

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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 mostly 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 Marketing Management.