Group Health Insurance Buying Guide

Minimum requirements

According to the Insurance Regulatory and Development Authority (IRDAI), any group with 7 or more members can get group health insurance. That being said, they’ve also given the discretion to the insurance providers to decide on the minimum size of the group they’d provide insurance to. So, most public insurers offer group cover only if you have 100 or more lives. And most private insurers need 50 or more lives.

At Plum, we follow the 7-member requirement wherein if your team has 3-4 members and their dependents (spouse, children, and parents), you can get group health insurance from Plum.

Exceptions

There are two exceptions to the 7 or more members rule:

If a company works primarily with contractual or part-time workers only, who are otherwise not qualified for group insurance, they can get so. This is only if their workforce is primarily part-time.
A company with most employees above 65 is also a particular case. This is because most insurers limit the entry age for the group health policy to 65 years (as per regulations). So, there are special provisions for companies with an ageing workforce to qualify for group health insurance.

Health benefits

Health benefits are aids that can be added to make your healthcare coverage more comprehensive. Here are some add-ons that make a good health benefits package:

Health and accident insurance: When choosing a health insurance plan, choose a plan that has no hidden terms and conditions, no tricky clauses, and no sub-limits. This ensures that the employees understand what their health insurance covers and has no unexpected surprises.
Doctor consultations: 95% + of the employees need consultations without hospitalization (which is not covered by insurance). Consulting doctors at the right time leads to early disease detection, faster recovery, and better health. Support the employees by enabling regular doctor consultations.
Health checkups: Annual preventive testing helps diagnose conditions at an early stage and prevent complications related to them. It also enables employees to be more aware of their health conditions.
Fitness plans: Health studies recommend five hours of moderate exercise per week. Exercise leads to higher energy levels and enhanced mood, directly resulting in enhanced productivity. Highly efficient organizations sponsor gym memberships for their employees. This shows that you care about their health and support their journey towards achieving their fitness goals.
Dental and vision plans: While general health care costs have been rising steadily, dental and vision-related care has been skyrocketing. Regular eye checkups, dental cleaning and checkup are critical for the long-term prevention of dental problems.
Mental wellness: Mental health has come to significant prominence in the past few weeks, especially with Covid-19. Poor mental health and stress can negatively affect employees’ job performance and productivity, engagement with one’s work, communication with coworkers, and physical capability and daily functioning. Set up a mental wellness plan and EAP program to ensure your employees can manage their work stress.
Nutrition plan: Nutrition is one of the most important yet neglected components of health and safety initiatives and workplace wellness programs. Nutrition has an immediate impact on employee performance. Provide your employees with the benefit of consulting nutritionists.

Considerations and Implications

GHI allows you to customize ~25 terms (aka benefits) in your policy. You must understand these terms and figure out what is best for your team.

If you are setting up GHI at your organization for the first time, this may seem like a herculean task. And you would eventually end up making the wrong choice, which will negatively impact the experience of your employees.

However, you can narrow your choices down by deciding on 4 significant considerations:

Members covered: GHI allows you to cover the employees and their family members. The three most common variants of GHI are:

E-plan: Covers employees only
ESC-plan: Covers employees, spouse, and upto 4 dependent children
ESCP-plan: Covers employees, spouse, upto 4 dependent children, and 2 parents

Sum insured: The second most impactful decision is the sum insured (SI), the maximum value for a particular year that the insurance company can pay if you are hospitalized. Organizations can choose a SI of as low as ₹50K or as high as ₹10L (or even more).
‍Maternity benefits: The third most impactful decision is to choose whether you want to add maternity as an add-on benefit to your GHI benefit. Coverage for maternity means you can claim your expenses related to pregnancy, including hospitalization, pre-hospitalization and post-hospitalization. Maternity benefit comes with a sub-limit (which is independent of your SI). You can opt for a maternity benefit starting from ₹25,000 to ₹1,00,000.
Pre-existing disease coverage: The fourth most crucial decision is to opt for pre-existing disease (PED) coverage. PED means any condition, ailment, injury, illness, or related condition(s) for which the insured had developed signs or symptoms and/or were diagnosed and/or received medical advice/treatment within 48 months before the first policy with the company.

To understand these considerations further, read this article

Cancellation

Here are three scenarios that lead to the cancellation of the Group Health Insurance Policy:

Cancellation by the policyholder: If you’ve bought group health insurance for your employees that you are dissatisfied with or have other reasons and wish to cancel the policy, you’d have to give prior notice to your insurance company. While most companies set the notice period at 30 days, some may have a shorter or longer duration. You must check the notice period at the time of purchase.
Automatic Cancellation: In the case of the policyholder’s death, the policy coverage is automatically terminated. And the refund is made following the parameters above if there have been no claims made under the policy.
Cancellation by the Insurer: Just like you, the insurer also has the right to cancel group health insurance. They, too, are required to provide you with a notice of 30 days (or whatever’s mentioned in the agreement), and they are liable to refund the amount of the premium.

Special Insurance Types: COVID Insurance

The Insurance Regulatory and Development Authority of India (IRDAI), released guidelines for Coronavirus insurance as an attempt to provide financial security to citizens specifically for COVID-19 treatment costs. IRDAI has directed all health insurance providers to provide short-term COVID-19 insurance plans based on the standard guidelines. Under the guidelines, two types of COVID-19 health insurance have been specified.

The Indian Government, through IRDAI, has mandated insurers to provide two types of Coronavirus coverage, depending on the people’s needs.

Corona Kavach: Corona Kavach is the standard health insurance policy for COVID-19 treatment. It works in a similar fashion to any indemnity-based health insurance policy where there is the sum insured, and you get the claim against the expenses you incur. For Coronavirus health insurance, these expenses range from diagnosis costs, to hospitalization charges and a lot more.
Corona Rakshak: Another option for COVID-19 health insurance to cover specific requirements is Corona Rakshak. This does not work like a standard insurance policy. Instead, the insurer provides you with a lump-sum amount of the sum insured after 72 hours of continuous hospitalization. This will be paid to you irrespective of the treatment expenses. Once this payment is made, your policy will cease to exist.

Explained: All about Corona Kavach and Corona Rakshak- What’s covered, inclusions And T&Cs