The productivity of any business is dependent on several factors. Employee satisfaction is a significant factor that impacts the way businesses start, grow, and thrive in this competitive environment. To keep their employees happy and engaged, organizations offer many benefits in the form of sick leaves, privileged leaves, etc.
One such benefit is the Group Medical Coverage Policy and the Group Personal Accident Policy, which takes care of all major unexpected events that may come in the life of the employees. Both these policies offer substantial medical and financial coverage to the employees to protect their welfare.
Group Medical Coverage Policy
Group Medical Policy is a tailor-made health insurance plan offered to a group of people, where the benefits offered are the same to all the members belonging to the group. This policy is taken by employers who customize them according to the needs of the organization. Since the risk is spread to a number of individuals in an organization, the premium for the policy is substantially lesser than individual medical insurance plans.
Regardless of the health risk factors of the employees in the organization, the same amount, and the same benefits are offered to the employees. Many organizations pay the total cost of the premiums, while some organizations charge a certain amount from the employees’ salaries.
The premium for the GMC policy is calculated using the following factors:
- Size of the group
- Demographic Factors (age of the members, income, occupation, etc.)
- Add-ons and Riders opted under the policy
What are the benefits offered under the GMC?
Hospitalization Expenses: All the expenses that occur while the employee is hospitalized is covered under this policy. The cost of the hospital stay, the medical amenities, and the equipment costs charged by the health institution is fully covered. In some cases, insurance policies also provide a cover for certain diagnostic procedures such as CT Scan, X-Ray, MRI, blood tests, etc. at an additional premium.
Pre and Post Hospitalization Expenses: The pre-hospitalization expenses such as doctor’s consultation fees, pathological tests, and post-hospitalization expenses such as tests to confirm the body’s response to the treatment, medicines, doctor’s follow-up, etc. are covered under the policy. However, depending upon the insurance company, this coverage is limited to 30 days of pre-hospitalization expenses and 60 days of post-hospitalization expenses.
Reimbursement of out-patient expenses: In some cases, employees have to undergo ENT, Ophthalmological, and dental treatments, pacemaker placement, dialysis, chemotherapy, which are not usually covered under the normal group medical insurance policy. However, at an additional premium, some companies provide these additional covers too.
Maternity care and infant health coverage: Group Mediclaim Cover also provides additional benefits to female employees in terms of covering the in-patient and out-patient expenses that occurred during maternity leave. Depending upon the type of insurance policy, prenatal and post-delivery medical care, and infant care benefits are provided to the employee.
Family Floater cover: Many organizations are extending their employee’s coverage to their family members too under which the spouse, children, and dependent parents/in-laws are covered under the policy. The single sum insured is available to all the entire family unit for a year.
Day Care Procedures: Any medical procedures that are conducted in a specialized daycare center under which the employee is discharged the same day, are covered under this policy.
Cashless Hospitalisation: Under the Group Medical Coverage policy, the insured employee can avail cashless treatment in any network hospital listed on the prospectus of the insurer.
What are the exclusions under the GMC policy?
Following are the permanent exclusions:
- Diseases caused due to drug or alcohol abuse
- Alternative treatments not specified under the policy
- Treatments done outside the policy’s geographical limits
- Injuries caused due to war, mutiny, military action, etc.
- Cosmetic treatments not specified in the policy
- Self-inflicted injuries
- Mental illnesses
- Experimental treatments
- Engaging in criminal or unlawful activities
Group Personal Accident Policy
Group Personal Accident Policy is a group insurance plan, which provides financial cover against unexpected events such as accidental death, injuries, or disability to the members belonging to the group. Any unexpected accident that occurs while the employee is on duty or not, or in the country or not is covered under this policy. Due to its extent of coverage, it is also called a 24-hour worldwide accident policy.
Benefits under the GPA Policy
Accidental Death: The death of the individual employee due to unintended, sudden, and unexpected accident is covered under the policy. All the medical expenses incurred in the treatment for the injury are covered under the policy based on the sum assured.
Dismemberment: Any accident that causes the incapacitation or dismemberment of any part of the body is covered under this policy.
Permanent, Total, & Partial Disability: If the accident results in a partial, or total disability, that leads to a continuous loss of a body part or a sensory organ, then the GPA will provide the compensation under the policy. In case of temporary total disablement, the cover is provided only if the bodily harm prevents the employee from getting back to work for a period of not more than 104 weeks from the date of the accident.
Additional Benefits: In addition to the capital sum assured, the following additional benefits are provided under the policy:
- The transportation cost of carrying the deceased person home including funeral charges.
- The cost of clothing damaged in the accident
- Ambulance charges
- Education fund for two dependent children after the death of the insured
Add-on Covers:
On the payment of additional premium, some insurance companies provide the following add-on covers are provided to the employees:
- The medical expenses incurred due to the accident up to 40% of Personal Accident Claim or actual expenses (whichever is less) is allowed.
- A daily allowance of Rs. 500/- for a maximum of 30 days if the person is hospitalized due to the accident.
What are the exclusions under this policy?
- Natural death
- Payments made after making the claim
- Fraudulent claims
- Death or injury due to:
- Suicide attempt
- Intentional self-injury
- Influence of drugs or intoxicating liquor
- Participating in adventure sports, hazardous activities
- Participating in any criminal or illegal act
- War, revolution, mutiny, military action, etc.
- Sexually Transmitted diseases
- HIV or other related diseases
What documents need to be submitted for availing a claim under the GPA Policy?
According to the IRDAI rules, the following documents need to be submitted depending upon the type of claim:
For Death Claim
- Duly filled up the claim form
- Death Certificate
- Original FIR
- Original Panchnama
- Post mortem report
For Permanent Total disablement/Permanent Partial Disablement
- Duly filled up claims form
- Original FIR
- Panchnama
- Hospitalization Report
- Hospital discharge card
- Original Certificate from Doctor of Govt. Hospital stating the degree of disability
- Termination letter for claim under “Loss of Employment”
For Temporary Total Disablement
- Duly filled up claims form
- Original FIR
- Panchnama
- Hospitalization Report
- Hospital discharge card
- Original Certificate from Doctor of Govt. Hospital stating the degree of disability
Frequently Asked Questions (FAQ’s)
- I am insured under my Group Medical Coverage policy of my company, however, I have exhausted the threshold cover. Is there any option where I can be covered even after the limit is crossed?
Ans. Technically, the coverage exists until the limit is crossed. However, some organizations provide a corporate buffer, which can include your case even after your coverage limit is crossed. You will need to check with your HR about this.
- In a Group Personal Accident policy, when can a person avail the weekly disability compensation benefit?
Ans. This benefit can only be availed if the person is officially on medical leave (paid or unpaid) due to the accident.
- I will be undergoing surgery for my ruptured hernia next week. Can I avail a private AC room under the Group Medical Insurance policy?
Ans. You will be able to avail of the type of room mentioned in the policy. If you plan to take a room that is not covered under your policy, you will have to bear the additional overhead costs of it.
- Is voluntary termination of pregnancy (abortion) covered under the GMC policy?
Ans. Abortion is covered only if it is advised by the doctors due to health complications for the mother.