July 1, 2022
Exclusions Under A Group Insurance Policy


Although the overall life expectancy of an average person has increased due to medical advancements, it is also true that the number of diseases and viruses that affect humans have also increased. Also, due to medical inflation, rising costs of healthcare facilities in India can be a huge pain and impact you financially. One way to be financially prepared against prospective health risks is by getting health insurance cover. Group mediclaim insurance plans are contracts between an insurance provider and its policyholder. The process works so that it is the policyholder who pays a certain amount of premium to the insurance company. In return, the insurance company takes care of medical expenses such as hospitalisation, daycare, etc. The policyholder can pay bills first and then get them reimbursed from the insurer. Whereas, if they opt for a cashless facility, medical bills will be directly settled by the insurance company with the hospital in case of any hospitalisation. The terms may depend on different insurers.

Suppose a company gets a proper health insurance plan which offers comprehensive coverage to its employees and decides to buy it. Commonly, medical insurance is offered on a yearly basis, and it has to be renewed each year after its expiry. During the term of its coverage, in case of any hospitalisation of an insured person, it’s natural that the person will make a claim for their healthcare needs. In such cases of a claim, the insurance company primarily checks whether the treatment required by the insured is covered under the insurance policy or not.

One of the disadvantages of this facility is that the employees do not have any say in group health insurance. Right from the network available, the deductible they would have to meet or the premium required to be paid is all taken care of by the employer. It could be an appropriate fit for one employee, but could offer limited or comparatively lesser benefits to other employees being covered by the same plan. These days, average costs have gone up & so have the increase in premiums and deductibles due to growing medical expenses.

What are the Cons of Group Mediclaim Insurance?

  • Not Individualised as it is taken for a pool of employees.
  • It can be expensive in most cases.
  • Employers’ policies for including family may vary.
  • It is not suitable for small-scale industries, as companies may not provide reasonable or all required benefits for fewer people.

Common Exclusions Under Group Mediclaim Insurance

Even though the plan’s scope under the group health insurance policies is exhaustive, the policies do have specific exclusions. Some of these common exclusions under this plan are as follows:

  • Cost of diagnosis.
  • Any kind of cosmetic surgery or gender reversal treatments.
  • Inorganic weight control treatments.
  • Surgical treatments for correction of vision.
  • Infertility treatments.
  • Medical conditions caused due to war, be it a direct or an indirect injury caused by military action involving nuclear materials or weapons.
  • Mental or physical rehabilitation expenses.
  • Expenses under maternity treatments.

How to choose the right group health insurance policy for your employees -  The Economic Times

Apart From The Above Common Points, There Are Certain Conditions Which Are Specifically Excluded Under Most Of The Group Plans:

  • Addictions, HIV/AIDS and drug abuse.
  • Stress, attempt to suicide, psychological disorders, intentional self-harm, and psychiatric conditions.
  • Congenital illnesses: A thin line of demarcation is made between external and internal congenital diseases.
  • Learning difficulties, issues in the sleep cycle, hyperactivity disorder.
  • Treatment costs for Homoeopathy and Unani also sometimes do not form a part of the coverage.
  • Treatments that are unproven, non-standard, or in the experimental stage are also excluded.
  • Most of the policies are applicable and effective only in specific geographies, so it will not be accounted for if the treatments are conducted outside a region.
  • Several employees covered under Group plans may wish to opt for routine Lasik or plastic surgery under cosmetic treatments. It should be noted that such aesthetic treatments are not a regular inclusion under Group covers.
  • High-cost treatments like stem cell treatment and robotic surgery.
  • Infertility, birth control, surrogate pregnancy.
  • Injuries sustained as a part of committing any criminal act.
  • Dangerous accidents such as an animal bite or snakebite.

Key Takeaways

For the employees to make the most of the coverages under a group health insurance, they must understand every line of the policy. Most of the employees prefer to opt for a workation in India, must specifically check for medical costs which can be covered in that particular region. Even though plans are designed and formulated in such a way that offers the best possible coverage, keeping a vigilant eye causes no harm. Most of the exclusions occur under rare circumstances, so it may not be a cause of concern for many.

Employees have all benefited immensely since the onset of group coverage. They feel valued and cared for. Individuals would like to work in an environment where their monetary goals are met, and their well-being is being taken care of. In this way, despite the exclusions, employers have retained their talent. Employees have successfully focused on their core work without worrying about medical expenses.