Employee Benefits
Group Mediclaim Insurance (GMC)
Group health insurance is a type of health insurance policy that provides coverage for a defined group of individuals, typically employees of a company, members of an organization, or members of a specific association.
What is Covered & What is Not Covered?
Covered in Group Health Insurance
- Medical Services: This includes doctor’s office visits, specialist consultations, surgeries, hospital stays, and outpatient care.
- Prescription Drugs: Group health plans often include coverage for a wide range of prescription medications. The specifics of drug coverage can vary, and some plans may have formularies that list which drugs are covered and at what cost.
- Preventive Care: Many group health plans cover preventive services at no or low cost to the members. This can include vaccinations, screenings, and wellness check-ups.
- Mental Health Services: Coverage for mental health and substance abuse treatment is often included, which may encompass therapy sessions, counseling, and inpatient or outpatient treatment.
- Maternity and Newborn Care: Group health insurance usually covers expenses related to pregnancy, childbirth, and care for newborns.
- Emergency Services: Coverage for emergency room visits and urgent care is typically part of the plan.
- Rehabilitation Services: This can include physical therapy, occupational therapy, and speech therapy.
- Dental and Vision Care: Some group plans offer optional dental and vision coverage as part of their benefits package, though these are often separate from the medical coverage.
Not Covered in Group Health Insurance
- Cosmetic Procedures: Group health insurance typically does not cover elective cosmetic surgeries or treatments unless deemed medically necessary.
- Experimental or Investigational Treatments: Treatments that are considered experimental or not widely accepted in medical practice may not be covered.
- Certain Dental and Vision Services: While some group plans offer dental and vision coverage as separate options, basic dental and vision care may not be included in the standard health plan.
- Long-Term Care: Expenses related to long-term care, such as nursing home care or assisted living facilities, are generally not covered.
- Infertility Treatments: Fertility treatments like in vitro fertilization (IVF) are often excluded from standard coverage.
- Weight Loss Surgery: Bariatric surgery for weight loss may not be covered unless it is deemed medically necessary.
- Certain Prescription Drugs: Some high-cost or specialty medications may not be included in the plan’s formulary, or they may require higher copayments.
- Cosmetic Dentistry: Cosmetic dental procedures like teeth whitening or veneers are typically not covered.
- Elective Procedures: Procedures that are elective and not medically necessary, such as elective plastic surgery, may not be covered.
- Out-of-Network Services: If you receive medical care from providers who are not in the plan’s network, you may be responsible for a significant portion of the costs.
- Non-Medical Services: Non-medical services like personal care, custodial care, and home modifications are usually not covered.
- Pre-Existing Conditions: While many group plans do cover pre-existing conditions, there may be waiting periods or limitations on coverage for certain conditions.
Frequently Asked Questions (FAQs)
What is room rent capping in health insurance?
A typical eligibility available while choosing type of room during hospitalization that ranges between 1-2% of the sum insured.
What are waiting periods in Group health insurance?
A waiting period is a specific time period during which the Insured is not eligible to avail coverage benefits for a listed group of ailments. What is health-check facility? By buying a health insurance plan with free preventive health check ups, one can avail the benefit to reimburse annual medical examination expenses.
Is congenital disease covered in health insurance?
It is a general exclusion in almost every insurance plan offered by Insurers. Is abortion covered under group health insurance? Self-inflicted or voluntary abortion is not covered group health insurance offered by most insurers.
