GMC and GPA Insurance Policy

GMC and GPA Insurance Policy

Group Medical Coverage (GMC) and Group Personal Accident (GPA) are two types of insurance benefits offered by employers. While both help protect employees, they cover different risks. GMC mainly covers eligible medical and hospitalisation expenses, while GPA provides financial support in case of accidental death or disability.

Knowing the difference between GMC and GPA helps employees understand what their company insurance covers and what additional protection they may need. In this guide, PolicyX explains GMC and GPA, their coverage, benefits, exclusions, and key differences.

Difference Between GPA and GMC Policies

Before delving deeper into GPA and GMC policies, it is essential to understand their key definitions.

Group Medical Coverage (GMC) is an insurance policy that protects employees in a company from hospitalization costs caused by medical conditions. Meanwhile, GPA provides coverage for accident-related disability and even death.

Which is Better: GPA or GMC Policy?

GMC is better suited for employees who want coverage for medical and hospitalisation expenses, including treatment for illnesses and injuries covered under the policy.

GPA is better suited for employees who want financial protection against accidents, especially accidental death or disability.

For employers, having both GMC and GPA can offer more complete employee protection, as GMC helps with medical expenses while GPA provides financial support after serious accidents.

Group Medical Coverage Policy

A Group Medical Policy is a tailor-made health insurance plan offering uniform benefits to all group members. Employers purchase and customize these policies based on their organization's needs. Since the risk is spread across many individuals, the premium for a group policy is substantially lower than individual medical insurance plans.

Regardless of individual health risk factors, employees receive uniform coverage and benefits. Many organizations cover the full premium cost, while others deduct a portion from employee salaries.

Factors Affecting GMC Policy Premiums

GMC policy premiums are calculated based on the following factors:

• Size of the group
• Demographic factors (age of members, income, occupation, etc.)
• Add-ons and riders opted under the policy

Benefits Offered Under GMC Policy

Hospitalization Expenses

This policy covers all expenses incurred during an employee's hospitalization, including hospital stay, medical amenities, and equipment charges. Some policies may also cover diagnostic procedures like CT scans, X-rays, MRIs, and blood tests at an additional premium.

Pre and Post-Hospitalization Expenses

Pre-hospitalization expenses (e.g., doctor's consultation fees, pathological tests) and post-hospitalization expenses (e.g., tests to confirm treatment response, medicines, doctor's follow-ups) are covered. Depending on the health insurance company, this coverage is typically limited to 30 days pre-hospitalization and 60 days post-hospitalization.

Reimbursement of Outpatient Expenses

While not typically covered under a standard group medical insurance policy, some companies offer additional coverage for treatments like ENT, ophthalmological, dental, pacemaker placement, dialysis, or chemotherapy at an extra premium.

Maternity Care and Infant Health Coverage

A Group Mediclaim Policy provides additional benefits to female employees by covering inpatient and outpatient expenses during maternity leave. Depending on the policy type, prenatal, post-delivery medical care, and infant care benefits are provided.

Family Floater Coverage

Many organizations extend coverage to employees' family members, including spouses, children, and dependent parents/in-laws. A single sum insured is available for the entire family unit for a year.

Daycare Procedures

This policy covers medical procedures conducted in a specialized daycare center where the employee is discharged the same day.

Cashless Hospitalization

Under the Group Medical Coverage policy, insured employees can avail cashless treatment at any network hospital listed in the insurer's prospectus.

Exclusions Under GMC Policy

• Diseases caused by drug or alcohol abuse
• Alternative treatments not specified in the policy
• Treatments performed outside the policy's geographical limits
• Injuries caused by 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

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Group Personal Accident Policy

A Group Personal Accident Policy is a group insurance plan that provides financial coverage against unexpected events such as accidental death, injuries, or disability to group members. This policy covers accidents whether the employee is on duty or not, and within or outside the country. Due to its extensive coverage, it is also known as a 24-hour worldwide accident policy.

Benefits of GPA Policy

1. Accidental Death

   The policy covers the death of an individual employee due to an unintended, sudden, and unexpected accident. All medical expenses incurred for treating the injury are covered based on the sum assured.

2. Dismemberment

   This policy covers any accident that causes incapacitation or dismemberment of a body part.

3. Permanent, Total, & Partial Disability

   If an accident results in partial or total disability, leading to a permanent loss of a body part or sensory organ, the GPA policy provides compensation. For temporary total disability, coverage is provided only if the bodily harm prevents the employee from returning to work for a period of not more than 104 weeks from the date of the accident.

4. Additional Benefits

   In addition to the capital sum assured, the policy provides the following additional benefits:

   • Transportation costs for carrying the deceased person home, including funeral charges.
   • Costs for clothing damaged in the accident.
   • Ambulance charges.
   • Education fund for two dependent children following the death of the insured.

5. Add-on Covers

   Upon payment of an additional premium, some insurance companies offer the following add-on covers to employees:

   • Medical expenses incurred due to the accident, up to 40% of the Personal Accident Claim or actual expenses (whichever is less).
   • A daily allowance of ₹500 for a maximum of 30 days if the person is hospitalized due to the accident.

Exclusions Under GPA Policy

• Natural death
• Payments made after a claim is settled
• Fraudulent claims

Death or injury resulting from:

• Suicide or attempted suicide
• Intentional self-injury
• Influence of drugs or intoxicating liquor
• Participation in adventure sports or hazardous activities
• Participation in any criminal or illegal act
• War, revolution, mutiny, military action
• Sexually transmitted diseases (STDs)
• HIV or related diseases

Documents Required for GPA Policy Claims

According to IRDAI rules, the following documents must be submitted, depending on the claim type:

For Death Claims

• Duly filled claim form
• Death Certificate
• Original FIR
• Original Panchnama
• Post-mortem report

For Permanent Total/Partial Disability Claims

• Duly filled claim form
• Original FIR
• Panchnama
• Hospitalization Report
• Hospital Discharge Card
• Original certificate from a government hospital doctor stating the degree of disability
• Termination letter for 'Loss of Employment' claims

For Temporary Total Disability Claims

• Duly filled claim form
• Original FIR
• Panchnama
• Hospitalization Report
• Hospital Discharge Card
• Original certificate from a government hospital doctor stating the degree of disability

Conclusion

GMC covers eligible medical and hospitalisation expenses, while GPA provides financial protection against accidental death or disability. For complete employee protection, employers can consider offering both. Always check the policy terms, coverage, exclusions, and limits before choosing a plan.