what are the practice in covering the mediclaim policies to an industrial employees? Whether we have to cover mediclaim to the employee, spouse and upto two children?
From India, Selam
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3From India, Selam
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Mediclaim differs from company to company. There are a number of policies that differ in respect of coverage and the amount of premium. However, it is not statutory that a company should provide mediclaim. Normally, those who are covered by ESI get medical facilities from ESI hospitals. The facility is also available for the family of the employee. Moreover, the medical facility provided by the ESI Corporation is on par with, and perhaps even better than, any health care policies mainly serviced by private agencies. Therefore, it is better to exclude employees covered by ESI from the mediclaim policy being implemented by the establishment.
Regards,
Madhu.T.K
From India, Kannur
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Regards,
Madhu.T.K
From India, Kannur
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Health Insurance Cover: Key Considerations
The health insurance cover (group mediclaim) is available with standard features that can be tailor-made to suit your requirements. A typical standard cover includes:
Coverage Details
- It covers the cost of treatment for any illness, injury, or disease that requires hospitalization for a minimum of 24 hours. This requirement is waived in cases where medical technology advancements no longer necessitate a 24-hour stay in the hospital, such as cataract, chemotherapy, radiotherapy, dialysis, etc.
Additional Features
- Covers all individuals between the ages of 3 months to 75 years.
- Does not cover any pre-existing disease or its complications.
- Does not cover maternity.
- Does not cover any claim arising from alcohol intake.
- Does not cover congenital ailments.
- No treatment, except those arising from accidents, is covered in the first 30 days of taking the cover (for the first time, i.e., not applicable on renewal).
- Certain ailments are excluded for the first 1 or 2 years.
- Capping on room rent eligibility per day basis - typically 1% of the sum insured available as room rent per day. For ICU, it is 2%.
- Capping on treatment of certain ailments - like cataract, hernia, hysterectomy, bypass surgery, etc.
Decisions Before Initiating Health Insurance Cover
1. Coverage for Whom - Options include: Employee Only, Employee + Spouse, Employee + Spouse + 2 Children. Covering parents is possible, but claims from them may significantly impact renewal premiums. For SMEs, it's recommended to avoid this in the first year. Once the policy is clearer, consider including these benefits from the second year.
2. Individual or Family Floater Basis - It is recommended to opt for insurance on a family floater basis, as it is the ongoing trend and provides better coverage for employees and their families.
3. Coverage of Pre-Existing Disease - Any ailment, sign, or symptom existing before the cover date is excluded. This condition can be waived by paying an extra premium, often resulting in a 50% loading on the base premium.
4. Child Cover from Day 1 - If insurance is provided on a family floater basis, children are typically covered from the 91st day. This can be modified to cover from day 1 of birth.
5. First 30-Day Exclusion - When the policy is first provided, there is an exclusion on any claim for the first 30 days, except in the case of an accidental claim. This can be waived by paying an extra premium.
6. First 1/2-Year Exclusions - Certain ailments are not covered for the first 1 or 2 years, such as cataract, piles, hysterectomy, etc. This clause can be waived by paying an extra premium.
7. Maternity Benefits - A standard policy may not cover maternity and its complications. Maternity benefits can be obtained by paying an extra premium.
Basic Exclusions
- Alcohol-related treatments and cosmetic/plastic surgeries are not covered.
- The hospital must be registered with local authorities and have a minimum of 15 beds in urban areas and 10 beds in rural areas, along with full-time qualified doctors/nurses, ICU, etc.
The policy should provide relevant risk coverage and be sustainable for both the insurance company and yourself in the long term. Otherwise, premiums may rise, or insurers may refuse to continue the cover if it becomes loss-making beyond their risk appetite.
Next, finalize the cover and offer it to multiple insurance companies.
Regards,
From India, New Delhi
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The health insurance cover (group mediclaim) is available with standard features that can be tailor-made to suit your requirements. A typical standard cover includes:
Coverage Details
- It covers the cost of treatment for any illness, injury, or disease that requires hospitalization for a minimum of 24 hours. This requirement is waived in cases where medical technology advancements no longer necessitate a 24-hour stay in the hospital, such as cataract, chemotherapy, radiotherapy, dialysis, etc.
Additional Features
- Covers all individuals between the ages of 3 months to 75 years.
- Does not cover any pre-existing disease or its complications.
- Does not cover maternity.
- Does not cover any claim arising from alcohol intake.
- Does not cover congenital ailments.
- No treatment, except those arising from accidents, is covered in the first 30 days of taking the cover (for the first time, i.e., not applicable on renewal).
- Certain ailments are excluded for the first 1 or 2 years.
- Capping on room rent eligibility per day basis - typically 1% of the sum insured available as room rent per day. For ICU, it is 2%.
- Capping on treatment of certain ailments - like cataract, hernia, hysterectomy, bypass surgery, etc.
Decisions Before Initiating Health Insurance Cover
1. Coverage for Whom - Options include: Employee Only, Employee + Spouse, Employee + Spouse + 2 Children. Covering parents is possible, but claims from them may significantly impact renewal premiums. For SMEs, it's recommended to avoid this in the first year. Once the policy is clearer, consider including these benefits from the second year.
2. Individual or Family Floater Basis - It is recommended to opt for insurance on a family floater basis, as it is the ongoing trend and provides better coverage for employees and their families.
3. Coverage of Pre-Existing Disease - Any ailment, sign, or symptom existing before the cover date is excluded. This condition can be waived by paying an extra premium, often resulting in a 50% loading on the base premium.
4. Child Cover from Day 1 - If insurance is provided on a family floater basis, children are typically covered from the 91st day. This can be modified to cover from day 1 of birth.
5. First 30-Day Exclusion - When the policy is first provided, there is an exclusion on any claim for the first 30 days, except in the case of an accidental claim. This can be waived by paying an extra premium.
6. First 1/2-Year Exclusions - Certain ailments are not covered for the first 1 or 2 years, such as cataract, piles, hysterectomy, etc. This clause can be waived by paying an extra premium.
7. Maternity Benefits - A standard policy may not cover maternity and its complications. Maternity benefits can be obtained by paying an extra premium.
Basic Exclusions
- Alcohol-related treatments and cosmetic/plastic surgeries are not covered.
- The hospital must be registered with local authorities and have a minimum of 15 beds in urban areas and 10 beds in rural areas, along with full-time qualified doctors/nurses, ICU, etc.
The policy should provide relevant risk coverage and be sustainable for both the insurance company and yourself in the long term. Otherwise, premiums may rise, or insurers may refuse to continue the cover if it becomes loss-making beyond their risk appetite.
Next, finalize the cover and offer it to multiple insurance companies.
Regards,
From India, New Delhi
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Your inputs were really useful. Thanks for it. I am also working on introducing mediclaim benefits to employees. Our startup IT company has approximately 80 employees and is based in Pune. Could you guide me on the features we should include in the first year to create an employee-friendly policy? Additionally, if possible, please suggest some good insurance service providers. I am currently evaluating Bharti AXA, Max Bupa, and Star Insurance. How do they compare?
Thank you.
From India, Pune
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Thank you.
From India, Pune
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In a startup environment, a lot depends on the constraints that you may have financially as well as the competitive landscape from where you are hiring employees (and their expectations to continue with the same benefits). I would suggest that you start with a standard health insurance cover, run it for a year, and then look at changing any benefits. The intention is to provide for a basic risk cover, and the bells and whistles can be added later.
Do call me or email me in case you need any further specifics.
Regards,
Deepak
From India, New Delhi
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Do call me or email me in case you need any further specifics.
Regards,
Deepak
From India, New Delhi
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Employee reference policy.doc