Group Health Insurance - Product Benefits

Group Health
Insurance – Product
Benefits
USP of Group Health Insurance
Scope of
Cover
Scope of Cover (Optional
Extensions)
Comparison vis-à-vis Retail Cover
Claim Process
• Claims are received when any of the Members in the
Policy are Hospitalized.
• Claims can be:
• Cashless
• Re-imbursement
Cashless
Claims
• These are generally received in case of planned
hospitalization, and if the member is admitted to a Network
Hospital.
• For Cashless claims, a pre-authorisation form is filled and
submitted by the Hospital to the Insurer.
• After screening the details and Policy wordings, the Insurer
informs the Hospital with an initial approval and the
treatment is started.
• Final settlement is done at the time of discharge.
Re-imbursement Claims
• These are generally received in case of unplanned
hospitalization, and if the member is not admitted to a
Network Hospital.
• For Re-imbursement claims the member has to submit the
Claims Form duly filled along with all the Bills, Prescriptions
and other supportive documents to the Insurer, and the
Insurer then settles the claim by transferring the money to
the account of the Insured member.
Endorsement Process
• The Changes/ Amendments being made in the Policy after
the inception of the Policy are known as Endorsements.
• For Example: Addition/ Deletion of Employees/ Members in
the Policy, Corrections in Health Cards etc.
Endorsement Process
• RiskBirbal has a dedicated Service team, which is
responsible for all the Post Sales Servicing.
• We need to educate the customer to route all the service
related queries to this team.
Endorsement Process
• We share the Endorsement template with the client for the
data to be shared in.
• Once the Data is received, we share the same with the
Insurer, and ask for the Premium Calculation.
• We share the Premium Calculation with the customer and
get the go through once the Payment confirmation is shared
by the Customer.
• The Payment confirmation is shared with the Insurer and
once the Endorsement is received, it is shared with the
customer.
Selection and
Fraud
• Wrong information about Renewal or
Fresh Policy.
• Incorrect Data
• Employee Count
• DOB
• Dependents’ Count
• May lead to Cancelation of Policy without
Refund.
Exclusions
• GMC/GHI does not cover the below
conditions:
• HIV AIDS
• Self Injury/ Suicide attempts
• Cosmetic treatments
• Injuries in War
• External Congenial Diseases
• Medical conditions caused
knowingly.
Maternity Benefit
• Maternity insurance is usually provided as an
add-on or additional rider with your main
health insurance policy.
• It covers expenses related to both baby
delivery options – caesarean and normal
delivery.
Cappin
g• Capping or sub-limit is the maximum
amount one can avail under a specific
heads covered in the Insurance plan.
• Most insurance companies have these sub
limits specified to allow availability of more
funds for other medical procedures.
• The standard Limits for Maternity start with
25K-35K, and can go upto 75K-75K.
Room
Rent
Sub-limit on room rent would mean that the insurer defines the

maximum amount it will pay towards the room rent. Mostly, this
limit is defined as a percentage of sum insured.
 So, a 1% per day cap in a policy with a sum insured of Rs3
lakh means that the insurer will only pay Rs. 3,000 per day
towards room rent.
 If you choose a room with higher tariff, you pay the difference
in the room rent and most of the other expenses as well. These
include: doctors’ fees, nursing fees and surgery costs. This is so
because the cost of medical procedures is linked to the room that
you choose. So, for the same line of treatment a person with a
twin-sharing room will pay less compared to a person with a
single room.
Whom to
suggest
Maternity can be suggested to the customer where:
1. Interested in ESK/ ESKP Policy.
2.Interested in Self only policy with Female Employees in the
company.
Whom Not to suggest

Maternity should not be suggested to the customer
where:
1. If the customer is concerned more about Pricing.
2. Self only Policy without any Female Employees.
3. In case the age of the Employees are on higher side.
Pre and Post
Hospitalization
• Pre-Hospitalization refers to the cost incurred
on Tests and Consultation related to the
disease and it can be re-imbursed, for a
maximum period of 30 Days prior to
Hospitalization.
• Post-Hospitalization covers the cost of tests
and other expenses incurred after discharge
from the hospital for a maximum period of 60
Days post discharge.
Pre-Existing
Diseases
PED refers to the present medical conditions and
means that all the members are covered
irrespective of their present medical conditions.
The members covered in the Policy can claim for
any disease from the very first day of policy
inception.
Corporate
Buffer
Corporate Buffer is a Buffer amount taken by the
company in the Policy for members in need
incase of a critical/ life threatening disease.
It can be released upto the sum insured incase
the initial sum insured gets exhausted and the
treatment is still not complete.
Co-
Pay
• Co-Pay is a mutually agreed upon condition
between the Customer and the Insurer, where a
percentage of the claim is beard by the customer
himself. For example, if the policy has a 10% Co-
Pay clause, and the claim amount is Rs. 1000,
then 90%, i.e. Rs. 900 is paid by the Insurer and
the rest 10%, i.e. Rs. 100 is borne by the
customer himself.
• It has an impact on the premium and the
premium is less with a co-pay condition in the
Policy.
Eligibility for
GMC
o Minimum Employee count must be 7.
o Ratio Between Employee and Spouse must be 0.5.
o Ratio Between Employee and Parents must be

1.5 times.
Types of
Coverage
o E(Self)
o ESK(Employee, Spouse, Kids)
o ESKP(Employee, Spouse, Kids and Parents)
o ESK & EP(Employee, Spouse & Kids/ Employee &

Parents)
Sum Insured and Sum Assured
• Sum Insured: A policy that offers a sum insured
works on the principle of indemnity. By
definition, indemnity means compensation for
any damage, loss or injury suffered. Non-life
insurance policies such as health, motor and
householder’s work on the principle of indemnity.
These policies only cover the losses on account of
any damage to the insured asset. Let’s take a
health insurance policy that offers a sum insured
of Rs1 lakh. If the insured person gets
hospitalized and has to pay Rs. 50,000, the
insurer will pay the entire amount.
Sum Insured and Sum Assured
• Sum Assured: It is a pre-defined benefit that the

insurer pays to the policyholder in case the
insured event takes place. For instance, in a life
insurance policy, the insurer promises to pay the
nominee a sum assured—a pre-decided amount—
in case of
the policyholder’s death. For this amount, the
policyholder pays a premium to the insurer. If the
policyholder dies during the term of the policy, the
insurer will pay the nominee the sum assured and
the policy terminates.
Thank
You

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Group Health

Whom Not to suggest

o Ratio Between Employee and Spouse must be 0.5.

o Ratio Between Employee and Parents must be

o ESK(Employee, Spouse, Kids)

o ESKP(Employee, Spouse, Kids and Parents)

o ESK & EP(Employee, Spouse & Kids/ Employee &

• Sum Assured: It is a pre-defined benefit that the

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