Features of a Group Mediclaim Policy

Employees are an asset to an organization .Today’s employee’s look beyond the traditional salary offered to them.

Hence the benefits apart from salary is also of importance to attract, retain and engage employees.

Group mediclaim policy is one of the most preferred benefits offered to employees. The features offered to employees depends on the company’s compensation philosophy and financial capability.

The general condition in mediclaim policy is 24 hours hospitalization with an active line of treatment.

Deciding on the features you intend to include as part of your mediclaim policy involves:

Decide Sum Insured
Sum Insured: An insurance policy that provides a sum insured works on the principle of indemnity. Non-life insurance policies such as health insurance work on the principle of indemnity.

If your employee has a sum insured of Rs 200000/- and he incurs Rs 150000 /- . Then the mediclaim company will reimburse the entire Rs 150000/- (within the terms and conditions of policy) to the employee.

However if the employee incurs a cost of Rs 300000/- . then the mediclaim company will reimburse only Rs 200000/-

The reimbursement by the mediclaim company will depends upon the terms of the mediclaim policy. If the policy states that a particular charge will not be covered by the policy, then irrespective of the fact that the cost is within the sum insured, the cost will not be reimbursed.

Eg : If Ramesh incurs a cost of Rs 50000/- . In this Rs 50,000/- Ramesh incurs Rs 1000/- for consultation charges and Rs 5000/- for food charges. But in the company mediclaim policy consultation charges are not covered and only 50% of food charges are permitted. So Ramesh will not be reimbursed the consultation charges and for food charges he will receive only Rs 2500/-  . Hence considering all other charges are as per mediclaim policy, then Ramesh will receive Rs 46500/-.

You need to decide the sum insured for your employees.You can set sum insured as per designation, grades, categories etc.

E.g :

  • Senior Managers : Rs 500000/-
  • Managers : Rs 300000/-
  • Asst Managers : Rs 200000/-
  • Executives : Rs 100000/-

Family Coverage

The company needs to decide which family members will be part of the mediclaim coverage.

The general principle is employee, spouse, 2 children, and 2 dependent parents.

Some employers also give the option to include In Laws instead of parents. However only two can be included (parents or in laws)

Co-payment parameters

Co-payment means a part/percentage of the medical expense is required to be paid by the employee. The insurance company is only liable to pay the balance claim amount, usually after the co-pay portion has been paid by the employee.

Co-payment can be decided for family members, certain medical treatments, Pre-existing disease.

The company can decide if co-payment is to be included.

It is not advisable to include co-payment for all members (self, spouse, child, parents) of the mediclaim. Generally companies include co-payment for parents.

For e.g :  Family members co-pay

  • For parents 20% co pay.
  • For spouse 10% co pay (apart from maternity cases)

If Ramesh incurs Rs 50000/- for his parents. Then 20% expenses need to be borne by him. So he will have to pay Rs 10000/-. The mediclaim company will pay only Rs 40000/-.

For e.g :  Treatment co-pay

It could be decided for xyz medical treatment the employee will have to bear 10% of the cost.

The main benefit in copayment policies is that the premium amounts are comparatively lower than the regular policies. Hence it is beneficial to companies. It also discourages employees from undergoing treatment in expensive hospitals and healthcare centers and from making unnecessary claims.

Corporate Buffer

The company creates a corporate buffer of a certain amount. Sometimes there are exigent circumstances wherein an employee or his dependent exhausts their sum insured. The company can then take the decision of availing certain amount from the corporate buffer to assist the employee. Corporate buffer amount is used generally by companies when the employee or hid dependent is suffering from a critical / life threatening illness. The prerogative to use corporate buffer lies with the company.

Expenses Covered

Pre-hospitalization expenses Investigations, Tests and other expenses incurred prior to hospitalization.

Hospitalization Expenses

  • Room charges and operation theatre charges
  • Fees of medical practitioner, anesthetist, and consultants
  • Cost of Ambulance , Prosthetic devices, medicines and drugs, surgical procedures, organ transplant, pacemaker, dressing ,ordinary splints and plaster casts, X-rays, dialysis, and chemotherapy, artificial limbs and organs, pathology tests,etc.

Post-hospitalization expenses: Follow up visits to doctor, medicines, investigation done after discharge from hospital.

Domiciliary hospitalization expenses: Domiciliary Hospitalization benefit means medical treatment for a period exceeding three days for such illness/disease/injury  which in the normal course require care and treatment at a hospital / nursing home but actually taken whilst confined at home in India under any of the following circumstances namely :

  • The condition of the patient is such that he/she cannot be removed to the hospital /nursing home or
  • The patient cannot be moved to the hospital/nursing home for lack of accommodation therein.

The exact clauses related to domiciliary hospitalization would be determined in the policy document.

Value Added Benefits

  • Nine month waiting period for maternity waived off
  • Baby Day one cover. Note: Some companies have a 90 day waiting period for new born baby.
  • Pre-Existing diseases covered: Any Pre-Existing ailments such as diabetes, hypertension, etc or related ailments for which care, treatment or advice was     recommended by or received from a doctor.
  • One/Two Years Waiting Periods waived off: There are certain listed ailments such as ENT disorders, hernia, osteoporosis, etc. for which health policies normally have one or two years of waiting period.

Day Care Procedures

Due to technological advancement a number of surgeries and medical procedures which required prolonged hospitalization can now be completed within 24 hours. These procedures are called day care procedures. Below are some examples:

  • Cataract Operation
  • Dialysis
  • Chemotherapy
  • Tonsillectomy
  • Angiography

The details of the Day Care procedures will be specified in the company’s mediclaim policy document.

Maternity benefits

Includes maternity related procedure/treatments arising from childbirth (including both normal delivery/Caesarean section, including miscarriage or abortion induced by accident).

Maternity has a different coverage rate in which they stipulate the maximum sum insured. It will be within the original sum insured.

For e.g : For Maternity – Normal Delivery ( Rs 50000/-) and Caesarean ( Rs 75000/-). So even if an employee has a mediclaim sum insured of Rs 200000/-. For a normal delivery claim the employee will receive only Rs 50000/-

Pre-hospitalization expenses are covered up to 30 days prior to delivery and will also cover post-hospitalization expenses up to 60 days

Pre and post-natal expenses – Maternity insurance covers expenditure related to both caesarian and normal delivery, as well as post-delivery complications for the mother.

Policy Exclusions

The below is an indicative list and the same will depend on the policy terms. The company can decide what the exclusion terms are:

  • Hospitalization for convalescence, general debility, intentional self-injury, use of intoxicating drugs/ alcohol
  • Hospitalization for diagnostic purposes only
  • Vitamins and tonics unless used for treatment of injury or disease
  • Infertility treatment
  • Voluntary termination of pregnancy
  • Any non-medical expenses like registration fees, Surcharge, admission fees, charges for medical records, cafeteria charges, telephone charges, etc.
  • Congenital external diseases/ defects / anomalies
  • HIV and AIDS and related disorders.
  • Non allopathic treatment/ Naturopathy
  • Circumcision unless necessary for treatment of disease
  • Dental treatment of any kind unless requiring hospitalization
  • Cost of spectacles, contact lenses, hearing aids

Sub-Limits, Day-Limits:

The limit on expenses allowed per-day in terms of doctor’s fee, medicines, and room-rent for a day, etc. are called sub-limits.

Claims Procedure

There are two types of health insurance claims:

  • Cashless: To avail of cashless treatment, one needs to avail of treatment in network hospitals. The insured person needs to provide his mediclaim details to the hospital. The hospital coordinates with the insurance company for processing the mediclaim. Network hospitals are those hospitals where there is an empanelment / tie up with the insurance company.
  • Reimbursement:In reimbursement claim the insured pays all the expenses related to the hospitalization of the insured and later after discharge claims a reimbursement from the company.

Documents for claim submission

  • Claim form duly filled and signed
  • Admission Card
  • Discharge Card
  • Consolidated Bill for the entire amount raised towards the treatment.
  • Itemized bill break up for all the details mentioned in the consolidated bill.
  • All relevant doctors’ prescriptions for investigations and medication
  • All bills for investigations ( Pathology , ECG, X Ray) done with the respective reports
  • All bills for medicines supported by relevant prescriptions
  • Incase of surgical packages – detail breakup of the package.
  • Treatment Details
  • Medicine Bills
  • Invoice / sticker for implants if used in the surgery
  • Medico Legal Certificate (MLC) / FIR in case of road traffic accidents (RTA)


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