Health Insurance · advanced
Group Health Insurance
Group health insurance explained — how employer plans are structured, sum insured and family cover, room rent and co-pay, pre-existing disease cover, claims and the TPA's role, and what happens at renewal or when a member leaves.
- 01Group Health Insurance — Structure, Eligibility & IRDAI FrameworkHow a group health policy is put together: the master policy and the people under it, who pays the premium, the rules that govern it today, what every member must be given, and what a conversion option is.
- 02Sum Insured Options — Flat vs Graded, Family DefinitionHow the sum insured is set in a group health policy: flat and graded structures, the family definition, what a restoration benefit does, and what decides the date from which a mid-year change takes effect.
- 03Corporate Policy Design — Room Rent, Co-pay, Network HospitalsThe design terms that decide how much of a hospital bill a group health policy pays — the room-rent limit and proportionate deduction, co-pay, the hospital network and non-medical items — with the arithmetic for each.
- 04Pre-Existing Disease Coverage in Group Plans (Day 1 Cover)What a pre-existing disease is, the 36-month cap on its waiting period and the 60-month moratorium, why some group policies cover pre-existing diseases from the day of enrolment, and what that day-1 cover does and does not change.
- 05Group Mediclaim vs Group Health Insurance — Key DifferencesWhere the word mediclaim comes from, why the difference between group mediclaim and group health insurance is a matter of usage and not of regulation, what every health policy must cover whatever it is called, and which benefits are optional extras.
- 06Claims Administration — TPA Role, Cashless Process, ReimbursementWho handles claims under a group health policy, how cashless and reimbursement claims work, the time limits IRDAI sets for each, and where a member can complain.
- 07Renewal, Portability & Conversion to Individual PolicyHow a group health policy is renewed and priced on its claims experience, who has the regulated right of portability, what conversion to an individual policy means for a leaving member, and the GST that applies to group premiums.
- 08Employee Communication & Wellness IntegrationWhat members of a group health policy need to be told and when, the role of the Customer Information Sheet, the wellness benefits some policies and employers add, and why the results of a wellness programme cannot be assumed in advance.