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List of Medical Expenses covered under Group Health Insurance policy


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Group health insurance policy is a type of health insurance policy under which the hospitalization expenses of the insured member are covered up to the sum insured mentioned under the policy. Group health insurance policy is usually taken by organizations to provide health insurance cover to their employees working in the organization.

Do look at the list of Medical Expenses Which are Covered and Not Covered Under Group Health Insurance Policy:

 

A) Group Health Insurance Medical Expenses Cover:- The group health insurance policy covers the medical expenses of the insured at the time of hospitalization. There are different types of medical expenses which are covered under the group health insurance policy which are mentioned below:-

    1.  Room Rent & Nursing Expenses: Room rent expenses and nursing expenses incurred as a part of the hospitalization due to any illness or disease is covered under the group health insurance policy. The room rent expenses is usually a percentage of the sum insured or a private single a/c room.
    2. Inpatient expenses: Inpatient hospitalization is when the patient is admitted in the hospital and undergoes treatment for more than 24 hours. The admission should be inpatient for the GHI policy to cover the expenses incurred on the treatment of the insured. The maximum inpatient expenses paid under the GHI policy would not exceed the sum insured mentioned under the policy.
    3. Pre hospitalization and Post Hospitalization expenses: The hospitalization expenses incurred prior to the surgery/operation are called the pre hospitalization expenses whereas the hospitalization expenses incurred after the surgery/Operation are known as post Hospitalization expenses. The pre hospitalization and Post Hospitalization expenses are covered up to a period of 90 days and 120 days respectively.
    4. Surgery expenses: The expenses incurred on performing a surgery due to any condition such as illness or disease is covered under the group health insurance policy. The surgical expenses include the room rent and surgeon expenses in addition to any other allied expenses.
    5.  ICU Charges: Intensive care unit charges are paid under the group health insurance policy subject to the need and requirement as prescribed by the treating doctor. The ICU Charges are paid as a percentage of the sum insured under the group health insurance policy. For instance the ICU Charges can be 2% of the sum insured. ICU charges are higher than the room charges as the facilities available under the ICU room are higher than those under the normal room.
    6.  Ambulance expenses: The expenses incurred for availing emergency ambulance services are paid under the group health insurance policy. The ambulance expenses from the place of accident to the hospital is paid up to a certain limit under the group health insurance policy. The ambulance limits would generally be a certain fixed amount and are payable per claim under the GHI policy. The ambulance expenses are paid for each and every hospitalization claim made under the group health insurance policy.
    7.  Ayush treatment expenses: The expenses for alternative treatments such as Ayurveda, Yoga, Unani, Siddha, Homeopathy commonly known as Ayush is payable under the group health insurance policy. The treatment under Ayush should be availed in a government recognised hospital for the expenses to be payable. Certain health insurance plans pay the complete sum insured while certain plans pay only a percentage of the sum insured for alternative treatment Expenses.
    8. Medical check-up expenses: The expenses incurred on medical check-ups are covered under the group health insurance policy. Most of the group health insurance policies reimburse the medical check-up expenses incurred by the members for availing health checkups during the policy period. These health check-ups could be referred to as preventive health check-ups

B) Medical Expenses not covered under Group Health Insurance: There are certain expenses which are not covered under the group health insurance policy which are mentioned below:-

    1. War/ Radiation induced expenses: Expenses incurred on War and allied perils, radiation etc are not covered under the group health insurance policy. Any expense arising out of a war/ war like situation is not covered under the group health insurance policy.
    2. Cosmetic Expenses: Expenses incurred for cosmetic treatments are not paid under the group health insurance policy. For instance the expenses incurred on plastic surgery to enhance beauty is not covered under the group health insurance policy. The expenses for plastic surgery due to any accident and as a requirement under the treatment for any accident or illness is paid under the group health insurance policy.
    3. Fertility related expenses: The fertility related expenses such as child birth, IVF, IUI etc are not paid under the group health insurance policy. These expenses are planned and are not accidental in nature. For instance the expenses incurred on infertility, surrogate pregnancy are not covered under the group health insurance policy.
    4. Intentional self injury: The hospitalization expenses incurred as a result of intentional self injury are not covered under the group health insurance policy. Any intentional self injury treatment is not covered under the GHI policy.
    5. Substance abuse: The expenses incurred for treatment of certain conditions such as substance abuse, alcohol abuse and drug abuse are not paid under the group health insurance policy. These expenses are mentioned under the permanent exclusions under the group health insurance policy.
    6.  HIV/AIDS: The expenses incurred on treatment of certain conditions such as HIV/ AIDS and sexually transmitted conditions are not covered under the group health insurance policy. These expenses are included under the permanent exclusions of the group health insurance policy.
    7. Non standard & unproven treatments: Any expense incurred on the non standard and unproven treatments are not paid under the group health insurance policy. For instance if a treatment is non-standard and is not approved by the appropriate authority, then the expenses incurred for such treatments are not paid under the group health insurance policy. The treatments which are non standard and unproven are considered as trail tests by most of the insurance companies and the claims are not paid.

C) List of Disease not covered under Group Health Insurance: There are certain diseases or illnesses which are not covered under the group health insurance policy. The list of those illnesses or diseases is mentioned below:-

  1. Pre-existing diseases: The pre existing diseases are not covered under the group health insurance policy for a certain period of time which is known as the pre existing disease waiting period. The pre-existing disease waiting period would range from 1 year to 4 years in the group health insurance policy. There would be an option to get the pre existing diseases cover from day 1 in the group health insurance policy. For more details on this, please book a call with Ethika insurance broking.
  2. Transmitted diseases: The transmissible diseases such as HIV, AIDS and other sexually transmitted diseases STDs are not covered under the group health insurance policy. Most of these diseases require prolonged and lifelong treatments and therefore are not covered under the group health insurance.
  3. Congenital diseases: There are two types of congenital diseases namely internal and external. Congenital diseases or genetic disorders are conditions of a person which are present from the time of birth and are there by birth. There are certain congenital conditions which are covered under certain group health insurance policies up to a certain specified percentage of sum insured.
Abhinay Naidu

Abhinay Naidu

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.

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.