Dear All,
Please read the note below, and then perhaps I could share with you how to structure a health insurance cover for your employees and the typical premiums an insurer may charge:
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: It covers the cost of treatment of any illness, injury, or disease that requires hospitalization for a minimum of 24 hours. (This is waived off in cases where medical technology advancements no longer necessitate a 24-hour stay in the hospital, for example, Cataract, Chemotherapy, Radiotherapy, Dialysis, etc.)
Moreover, the following are features of the same:
- Cover for all individuals between the age groups of 3 months to 75 years of age
- 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 for accidents is covered in the first 30 days of taking the cover (for the first time, not applicable on renewal)
- Certain ailments are excluded for the first 1 year/2 years
- Capping on room rent eligibility per day basis - typically 1% of sum insured available as room rent per day. For ICU, it is 2%
- Capping on the treatment of certain ailments - like cataract, hernia, hysterectomy, bypass surgery, etc.
Please note the following decisions need to be taken before you initiate the health insurance cover:
1. Coverage for Whom - The options are - Employee Only, Employee + Spouse, Employee + Spouse + 2 Children. There is a possibility of covering your parents as well, but considering that claims from them will likely be higher than the claims of other members, it will have a significant impact on your renewal premiums. For SMEs, it is recommended to avoid this in the first year of taking the cover. Once the policy and its workings are clearer, please discuss including these benefits from the 2nd year.
2. Coverage on an individual basis or a family floater basis: It is recommended to opt for insurance on a family floater basis. It is the ongoing trend nowadays and is a better way of providing coverage to employees and their families.
3. Coverage of Pre-Existing Disease: Any ailment, its sign, or symptom existing before the cover date will be excluded from the policy. Any resultant complications will also be excluded. This condition can be waived off by paying an extra premium, typically resulting in a 50% loading on the base premium.
4. Child Cover from Day 1: If the insurance is provided on a family floater basis to the immediate dependents of the employee (spouse and children), children are often covered from the 91st day onwards. This can be modified to cover the child from day 1 of birth.
5. First 30-day exclusion: There is an exclusion on any claim for the first 30 days when the policy is provided for the first time, except in the case of an accidental claim. This can be waived off by paying an extra premium - loading on the base premium.
6. First 1/2-year exclusions: There are certain classes of ailments whose treatment is not covered under the policy for the first 1/2 years. Typically, these include Cataract, Piles, Hysterectomy, etc. This clause can be waived off by paying an extra premium - loading on the base premium.
7. Maternity Benefits: A standard policy may not cover maternity and related complications. By paying an extra premium, you can obtain maternity benefits for your employees.
Some basic exclusions include - Alcohol-related treatments are not covered, cosmetic treatments/plastic surgeries are not covered, etc. The hospital where treatment is taken should be registered with local relevant government authorities and/or have a minimum of 15 beds in urban areas and 10 beds in rural areas, along with full-time and qualified doctors/nurses, ICU, etc.
What I have provided above is a brief of the options you need to consider before initiating the insurance policy. The policy should not only provide relevant risk coverage but also be sustainable for the insurance company and yourself in the years to come. Otherwise, the premiums will rise, or insurers may refuse to continue the cover if it becomes loss-making beyond their risk appetite.
Next is to finalize the cover and float it to multiple insurance companies.