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Maternity Benefits in Group Health Insurance Policy


Maternity Benefits in Group Health Insurance - vector image of a pregnant woman

Group health insurance is a customized health insurance policy in which the coverage can be customized as per the needs and requirements of the customer. Group health insurance policy covers the hospitalization expenses of the members due to any illness or disease as mentioned in the policy copy. The premium of the group health insurance policy depends on the options exercised by the customer.

The minimum group size for a group health insurance policy is 7 lives or more and it depends on company to company. A group health insurance provides the facility to include the family members in payment of additional premiums in certain cases.

The most common question people ask regarding the group health insurance policy is whether the maternity is covered under the group health insurance policy? The answer to this question is, that maternity can be covered in the group health insurance policy and the limits would be decided by the employer. The employer of the organization decides on taking the maternity benefit in a group health insurance policy.

Baby cover upto 90 days would also be available with the maternity benefit under the group health insurance policy.

Maternity cover in group health insurance can be taken by the employer if there are a minimum number of female members in the group and they are of the child-bearing age.

Maternity cover should be taken after due consideration as the premium payable under the group health insurance policy would drastically increase with the addition of this option.

Maternity cover in group health insurance:

Group medical insurance for pregnancy would be available under the group health insurance policy with or without the specific waiting period. The waiting period for maternity cover would normally be 9 months but the group health insurance policy provides the option of availing maternity cover from the day.

1. The sum insured for maternity cover can be specified in the group health insurance policy. Maternity charges for Normal and Cesarean would be different. For example, if the normal maternity expenses are Rs.25k then the cesarean charges would be ₹.35k in the group health insurance policy.

The maternity expenses in the group health insurance policy would be decided by the employer taking the policy. Maternity cover requires hospitalization of the insured member and the room rent, nursing charges, surgeon charges, etc are covered under the group health insurance policy up to the limit mentioned in the policy. The maternity sum insured is over and above the basic sum insured mentioned in the policy.

The newborn cover if diagnosed with any illness or disease would be covered under the group health insurance policy within the maternity sum insured or the basic sum insured. The group health insurance policy covers the newborn up to a period of 90 days from birth, including vaccinations after which the newborn would be added as a separate member in the policy on payment of additional premium.

Addition and Deletion in group health insurance:

The addition and deletion of members in the maternity cover in the group health insurance policy would be done on intimation to the insurance company. Mid-term additions and deletions would be processed as per the confirmation received from the employer and the premium would be charged or refunded on a pro-rata basis.

In the group health insurance policy, the addition would take place only if there is an event of marriage happening to the member.

Scenario 1: Mr. John was a member of the group health insurance policy, recently married, and wants to include his spouse in the group health insurance policy. This can be done on payment of additional premium and there would be no waiting period to avail maternity claim under the group health insurance policy.

Scenario 2: Mr. Kurien had enrolled in the group health insurance policy at the starting of the policy period but did not include his spouse. In this case, the mid-term addition of a spouse would not be permitted and maternity benefits would not be available to his spouse as there is no event that has happened (marriage in this case) after the inception of the policy. The spouse can be added only at the time of renewal and subsequently, maternity benefits can be claimed.

Scenario 3: Mrs. Rosy has recently joined the organization and enrolled under the group health insurance policy. She was 6 months pregnant at the time of joining the organization. She would be eligible for the maternity benefit immediately as there is no waiting period under the group health insurance policy. In this case, she has joined mid-term in the group health insurance policy and is eligible for a maternity claim.

A procedure to avail maternity cover in group health insurance:

The procedure to avail of group medical insurance for pregnancy is mentioned below:-

Step 1: At first, it is important to confirm whether the maternity benefit is available under the group health insurance policy offered by your employer. If the maternity cover is available under the group health insurance policy, then the employee has to intimate the insurance company of the maternity claim.

Step 2: Maternity claims can be availed either as cashless or reimbursement. Members of the group health insurance policy can visit any of the network hospitals and avail cashless claim settlement facility. In case the network hospital is not available, then treatment can be availed in non network hospital and claim the reimbursement from the insurance company.

Step 3: Group medical insurance for pregnancy can be availed from the group health insurance policy up to the limit specified under the policy. The limits for normal delivery and cesarean would be mentioned separately under the group health insurance policy.

Maternity claim in group health insurance:

It is important to note that the group medical insurance for pregnancy would be available only up to 2 deliveries in the lifetime of a member. For example, if a member has two children already and is willing to avail of group medical insurance for pregnancy, then it would be rejected by the insurance company as the limit of 2 children in the lifetime of a member is exceeded.

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.