Definition of Group Health Insurance Policy

A group health insurance policy is essentially a mediclaim policy taken by an organization for its employees. A group medical insurance provides coverage to the whole group under one umbrella plan. Premium is paid by the organization. Organization can cover the employee and their direct dependents including spouse,children and parents. Such a plan can be customized depending upon the budget and requirements of the client.

Functioning of a Group Health Insurance Policy :

Group health insurance scheme are offered as healthcare benefits to employees. A basic plan is selected for all the employees while members can choose to add dependents based on their requirement and policy conditions. A group health insurance acts in a distributed manner, wherein a larger group pays towards bearing health issues for the less fortunate ones. So, the premiums become less as overall risk taken by the insurance company is spread across the group, thi

Group health insurance can be applied both online and offline. Offline you’ll have to book an appointment with our representative. In cities where we have our branch, we would be happy to meet you in person.  If you are in a city, where we do not have a branch, we would be happy to engage with you over phone, email and video conference. We also provide round the clock claims and other service support like renewal, addition of new employees and dependents, and deletion of exiting members.

Who are covered:

Employees (E)

Spouse (E+S)

Dependant Children (E+S+C)

Parents (E+S+C+P)

Group health insurance plans generally cover the employee, their spouse and children. Some group health policies also allow addition of dependent parents.These health insurance policies provide cover for pre-existing ailments, maternity, day-care charges and even ambulance charges in some cases. Medical insurances for employees generally offer a cashless hospitalization at network hospitals. Some health insurances also provide reimbursements and covers for pre and post-hospitalizations also

BENEFITS

• Reimbursement of reasonable and customary expenses incurred towards hospitalization for treatment of the disease, illness, medical condition or injury contracted or sustained by Insured Persons during the Period of Insurance subject to terms, conditions, limitations and Exclusions.
• The Insured Person should be hospitalized as an In-Patient during the Period of Insurance for a minimum period of 24 hours.
• However this time limit is not applicable to the following specific treatments: Dialysis, Chemotherapy, Radiotherapy, Eye surgery, Cataract, Lithotripsy (kidney stone removal) Tonsillectomy, D&C, Cardiac Catheterization, Hydrocele Surgery, Hernia repair surgery, Treatments for Fracture and such other Surgical Operation that necessitate hospitalization less than 24 hours due to medical/technological advancement / infrastructure facilities.
• Cashless Facility: This coverage can be extended to provide Cashless Facility through TPA – Third Party Administrator
• Addition/deletion facility

GENERAL BENEFITS: – at no additional premium

• Family floater cover
• Waiver of Pre-existing Disease
• Waiver of 30 Days waiting period
• Waiver of First Year exclusions.
• Maternity Treatment Charges Benefit Extension without waiting period at inception which is extended.
• Pre-Hospitalization expenses for 30 days
• Post-Hospitalization expenses for a period of 60 days after discharge from the hospital is allowed when the original claim for hospitalization is admitted under the policy.

Expenses covered under the Policy

• Room, Boarding Expenses as provided by the Hospital/Nursing Home
• Nursing Expenses.
• Surgeon, Anesthetist, Medical Practitioner, Consultants & Specialist Fees
• Anesthesia, Blood, Oxygen, Operation Theatre Charges, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Donors medical expenses towards Organ transplant, Cost of Pacemaker, Artificial Limbs, Cost of Organs.

SPECIAL EXTENSIONS: – at additional premium

• Tele Medical consultations
• Out Patient expenses ( Diagnostics / Medicines / consultations )
• Health check up costs
• Wellness Benefits
• Corporate Buffer : It is a common pool of coverage maintained at an organization level. This can be availed in case of any medical emergency falling under listed critical illness, after exhaustion of individual employee’s Family Floater coverage. This is extended to Employee, Spouse, Parents & Children.

EXCLUSIONS

The Company shall not be liable under this Policy for any claim in connection with or in respect of:

• Circumcision unless necessary for treatment of a disease, not excluded hereunder or necessitated due to an accident.
• The cost of spectacles, contact lenses and hearing aids.
• Dental treatment or surgery of any kind unless requiring Hospitalization.
• Convalescence, general debility, `Run-down’ condition or rest cure, Congenital External Disease or defects or anomalies, Tubectomy, Vasectomy, Venereal disease, intentional self injury or attempted suicide.
• All expenses arising out of any condition directly or indirectly caused by or associated with Human T-Cell Lymphotropic Virus Type III (HTLB-III) or Lymphadenopathy Associated Virus (LAV) or the Mutants Derivative or variations Deficiency Syndrome or any Syndrome or condition of a similar kind commonly referred to as AIDS.
• Charges incurred at Hospital or Nursing Home primarily for diagnostic, X-ray or laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of the positive existence or presence of any ailment, sickness or injury, for which confinement is required at a Hospital/Nursing Home.
• Expenses on vitamins and tonics unless forming part of treatment for injury or disease.
• Directly or indirectly caused by or contributed to by nuclear weapons/materials or Radioactive Contamination.
• Directly or indirectly caused by or arising from or attributable to War, Invasion, Act of Foreign Enemy, War-like Operations (whether war be declared or not) and Terrorism (including Chemical and Biological Terrorism).

            “Chemical” shall mean any compound which, when suitably disseminated,  

              produces incapacitating, damaging or lethal effects on people, animals, plants   

              or material property.

             “Biological” shall mean any pathogenic (disease producing) micro-organism(s)  

               and/or biologically produced toxin(s) (including genetically modified organisms    

               and chemically synthesized toxins) which cause illness and/or death in humans,  

               animals or plants.

• Directly or indirectly caused by or arising from or attributable to Ionizing radiation or contamination by any Nuclear fuel or from any Nuclear waste from burning Nuclear fuel , Radioactive, toxic, explosive or other dangerous properties of any explosive nuclear machinery or part of it.
• Any routine or preventative examinations, vaccinations, inoculation, or screening.
• Sex change or treatment, which results from, or is in any way related to, sex change.
• Hormone replacement therapy.
• Treatment of obesity (including morbid obesity) and any other weight control programs, services or supplies.
• The treatment of psychiatric, mental or nervous conditions, insanity.
• Any cosmetic, plastic surgery, aesthetic or related treatment of any description, including any complication arising from these treatments, whether or not for psychological reasons, unless medically necessary as a result of an accident.
• Use of intoxicating drugs alcohol and the treatment of alcoholism, solvent abuse, drug abuse or any addiction and medical conditions resulting from, or related to, such abuse or addiction.
• Any treatment received in convalescent homes, convalescent hospitals, health hydros, nature cure clinics or similar establishments.
• Any stay in Hospital for any domestic reason or where there is no active regular treatment by a specialist.
• Any treatment received outside India.
• Any Ayurvedic, Homeopathic, Naturopathy or any other system of medication.
• Complication of any surgery, therapy or treatment administered on the Insured Person which is not prescribed or required by a Registered Medical Practitioner/Registered Medical Institution in their professional capacity.
• Taking of drug unless it is taken on proper medical advice and is not for the treatment of drug addiction.
• Any fertility, sub-fertility or assisted conception operation.
• Any treatment arising out of Insured person whilst engaging in speed contest or racing of any kind (other than on foot), bungee jumping, parasailing, ballooning, parachuting, skydiving, paragliding, hang gliding, mountain or rock climbing necessitating the use of guides or ropes, pot holing, abseiling, deep sea diving using hard helmet and breathing apparatus, polo, snow and ice sports and activities of similar hazard.

Explanations mentioned in “What’s Covered & What’s Not Covered?” are illustrative and will be subject to terms, conditions and exclusions of the Policy. Please refer to the Policy Document for more details

1. Claims Procedure

• For opting Cashless Facility: (applicable where the Insured has opted for cashless facility and has paid the Third Party Administrator’s fees) – The Insured Person must call the helpline and furnish membership no and Policy Number and take an eligibility number to confirm communication. The same has to be quoted in the claim form. The call must be made 72 hours before admission to Hospital and details of hospitalization like diagnosis, name of Hospital, duration of stay in Hospital should be given. In case of emergency hospitalization the call should be made within 48 hours of admission.
• Reimbursement Claims – Preliminary notice of claim with particulars relating to Policy numbers, name of the Insured Person in respect of whom claim is made, nature of illness/injury and name and address of the attending Medical Practitioner/ Hospital/ Nursing Home should be given to Us within seven days from the date of hospitalization /injury/ death, failing which admission of claim is at Insurer’s discretion.
• Please ensure that the insured/insured person send the claim form duly completed in all respects along with all the following documents within 30 days from the date of discharge from Hospital.
  • Original Bills, Receipt and Discharge certificate / card from the Hospital.
  • Original Cash Memos from Hospital(s)/Chemist(s), supported by the proper prescriptions and Original Receipt and Pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner / Surgeon demanding such Pathological tests.
  • Surgeon’s certificate stating nature of operation performed and Surgeons’ original bill and receipt.
  • Attending Doctor’s / Consultant’s / Specialist’s /
  • Anesthetist’s original bill and receipt, and certificate regarding diagnosis and Medical Case History / Summary.

Benefits of Group Health Insurance Policies for employees

Extensive coverage: Most group health insurance policies provide coverage for most kind of hospitalization and daycare procedures.

Coverage for pre-existing ailments: Pre-existing ailments are covered from Day 1, i.e., all diseases are covered from the day of joining the group insurance policy scheme without any waiting period.

No waiting period for specific ailments: Generally, individual health insurance policies have waiting periods for specific diseases such as cataract, hernia and knee replacement. This can vary between 12-48 months. But for the group insurance policies, this waiting period is waived.

Maternity Coverage: Most group insurance plans taken for self and family provide maternity cover for both C-section and normal delivery. Some plans also cover the new born from Day 1.

Domiciliary hospitalization: Under group health insurance domiciliary hospitalization is by default covered by a few insurer while a few also cover them on demand.

Benefits of Group Health Insurance Policy for Employers

Cost Saving: Premiums of group employees are nominal and far less as compared to individual policies. As a group medical policy has risk distributed across the group, so the premiums tend to be lower.

Garnering goodwill of employees: When an employer shows responsibilities of taking care of the health and well-being of their employees, proven results show that employees’ productivity and loyalty to their employers increases. This also increases employee retention and sets the employer at par against other competitors in the eyes of the employees.

No medical underwriting: Most group health insurance plans have no clause associated with buying them, they are simple to understand and operate. They do not have pre-medical tests or paperwork associated that saves.

Easy claim settlement process: Dedicated Team for claim settlement of Group Health policies. Hence the processing is faster.

Rationale to protect your employees’ health from Group Health Insurance Policy

Employee retention rate has been proven to be higher for organizations that value their employees and provide added services to them. Group health insurance policy is a value-added benefit for the employees and it motivates them to perform better. So, if you cover your employees in sickness, their performance also improves.

Employer-Employee Life Insurance Scheme

You can Help your employees protect their loved ones by assuring financial security to their beneficiaries in the event of their death, thus acting as a great retention tool.

Our integrated employer-employee insurance schemes help you cover the most prized assets of your organisation, employees, against unforeseen events, thus securing their family’s financial future.

Why Choose Employer-Employee Life Insurance Scheme?

• The primary reason for availing employer-employee insurance is to boost your employees’ morale and give them peace of mind. By taking an interest in the well-being of your employees, you can leverage their potential to the maximum.

• Acts as a great tool to attract and retain talent

• Secures the financial future of your employees’ family

• Helps lower employer tax liability*

• Customised plans to suit everyone’s requirement.

 Life Insurance Keyman Insurance Policy: Keyman Insurance Policy: Features, Advantages & Benefits

There are different types of life insurance policies available to cater to the varying needs of people. Of these, Key Man Insurance is a policy that offers financial coverage to a company for the loss of any of its key employees. This is an important policy for organisations to manage the setback of losing a critical employee. 

Who is a Keyman?

Every company has a range of employees with defined roles and responsibilities. Of these, some employees play a critical role in the functioning, performance, or profitability of the company. These employees can be the best salespeople, decision-makers, high-level executives, or even junior IT employees that are playing a crucial role in the company’s performance.

The organisation determines a set of ‘key’ employees that contribute significantly to its performance and/or growth. The loss of such an employee can result in losses due to profit reduction and/or the cost of replacing the keyman.

What is Keyman Insurance Policy?

When a company feels that the loss of certain employees can significantly impact its performance, then it purchases a Key Man Business Insurance Policy where:

• The policy is proposed by the company
• Premium payments are made by the company
• The life of ‘key’ employees is insured for a fixed amount
• The company is the beneficiary of the policy

Hence, a keyman policy offers coverage to the company for the losses arising due to the death of its key employees.

Features of Key Man Insurance

While earlier, employers could purchase endowment life insurance plans with maturity benefits or term insurance as Key Man Insurance, IRDAI has now made it mandatory for them to only purchase term insurance as Key Man Insurance.

The ‘keyman’ should not hold more than 51% of the company’s shares. Also, the total shares held by the keyman and their family should exceed 70% of the shares of the company.

The maximum sum assured under Key Man Insurance is the lesser of:

• Three times the average gross profit of the company over the last three years
• Five times the average net profit of the company over the last three years
• 10 times the annual compensation of the keyman

The maturity date of the policy is usually equal to the retirement date of the employee or the expiry date of the contract between the employee and the company.

Add-on covers and loans against the policy are not permitted

The company can be the only nominee

Benefits of Keyman Insurance

• Financial protection to the company from losses due to the death of its key employees
• The premium paid for a Keyman Insurance Policy can be treated as Business Expense u/s 37(1) of the Indian Income Tax* Act, 1961
• Helps boost the morale of critical employees and helps improve retention and productivity
• Keeps the company’s share price relatively stable since investors feel assured of minimal financial impact due to the death of a key employee if the company has Key Man Insurance
• It helps boost the valuation of the company since it has a monetary backup if it loses its key employee

Keyman Insurance Policy Tax* Treatment

Here are some important things to know about Keyman Insurance Policy Taxability:

Premium paid by the company

Companies can treat the premium paid as a business expense and claim tax* deductions under Section 37(1) of the Income Tax* Act, 1961. This can help reduce the tax* liability of the company.

Death Benefits that the company receives

If the key employee dies, then the company receives the death benefit. This amount is taxable at the existing tax* rates.

If the employee of the company leaves their job, then the employer can assign the insurance policy to that employee, who can specify a nominee who will receive the death benefits. In such cases, the death benefit becomes an addition to the income of the employee and is taxed as per the rates applicable to them.

Conclusion

A Key Man Business Insurance Policy offers liability management and continuity to the company. It also helps boost employee morale and leverages tax* deduction benefits. It is primarily a term life insurance policy with the company as the nominee. If the policy matures without the death of the key man, then the company will receive no death benefit.

Documents and Details Required: