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How To Manage Group Mediclaim Policy Effectively?

A group Mediclaim policy is a kind of health insurance that provides coverage for individuals who are employed by the same company. Given that the business pays the cost, it is frequently provided as a useful benefit to employees. In some circumstances, the employee's family may be covered by the group health insurance.

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However, the cost is significantly lower than individual health insurance plans, and companies also benefit from tax breaks, making it advantageous for both the employer and the employee.

What is covered in Group Mediclaim Insurance Policy?

A Group Mediclaim Insurance Policy covers all the following aspects-

Room and boarding
Doctors/Medical Practitioner fees
Intensive Care Unit
Nursing expenses (within the room rent charges)
Surgical fees, operating theatre, anesthesia and oxygen, and their administration
Drugs and medicines consumed on the premises
Hospital miscellaneous services (such as laboratory, x-ray, diagnostic tests)
Costs of prosthetic devices if implanted during a surgical procedure
Radiotherapy and chemotherapy

A Group Mediclaim Insurance is applicable only if the below-mentioned criteria are followed:

They occur in India and are covered by the policy's time frame.
Hospitalization costs for a minimum of 24 hours are allowable.
If a covered member chooses a room with a higher rent category than what is allowed for him, the corresponding deductions will be made.

What is not covered in Group Mediclaim Insurance Policy?

Nuclear dangers, war, and war groups
Birth control methods, hormone replacement therapy, medically assisted pregnancy termination during the first 12 weeks following conception, and treatments resulting from or linked to pregnancy.
Circumcision unless required for a disease, illness, or injury not excluded hereunder, or as may be required as a result of an accident Vitamins and tonics unless part of treatment for a disease, illness, or injury as certified by the attending Medical Practitioner Ectopic pregnancy proven by diagnostic means and certified to be life-threatening by the attending Medical Practitioner
Routine medical, eye, and ear exams, the cost of glasses, laser eye surgery, contacts, or hearing aids, the issuance of medical certificates, and tests to determine eligibility for employment or travel
Self-medication, family member treatment, or any other kind of treatment not approved by science
Sex change or any form of treatment that arises from or is connected to sex change
Following the use of intoxicating substances and alcohol, medical treatment may be necessary. It also applies to drug abuse, solvent abuse, any addiction, or other medical conditions caused by or connected to such misuse or addiction.
Any medical care received in nursing homes, hospitals, hydrotherapy centers, natural medicine practices, or other comparable facilities
Any medical care received outside of the hospital without being admitted as a patient
Costs associated with donor selection or care
Treatment with naturopathy
Treatment received from individuals who are not medical practitioners as defined by the relevant medical bodies.
Any hospital stay during which no treatments are received, or the medical practitioner is not providing active regular treatment
Aesthetic procedures, cosmetic surgery, and plastic surgery, unless they are required as a result of an accident or as part of a condition that is not specifically prohibited.
Ionizing radiation or radioactive pollution from any type of nuclear fuel or nuclear waste that results from burning nuclear fuel
Nuclear weapons, nuclear materials, or radioactive contamination can cause or contribute to disease, illness, or injury either directly or indirectly.
Unproven and experimental therapies
Expenses incurred for medications that were not prescribed by a physician
Prosthetics, corrective equipment, and medical devices that are not necessary during surgery or for the condition, illness, or injury for which the insured or insured person was hospitalized and that are not otherwise excluded under this clause.
All illnesses, injuries, and diseases brought on by or connected to HIV, including the Acquired Immune Deficiency Syndrome (AIDS), the AIDS-related complex syndrome (ARCS), and others.
Orthodontic Care
Treatment for obesity, general sluggishness, recuperation, ailing condition or rest cure, venereal disease or purposeful self-harm, and usage of intoxicating substances such as alcohol
Any type of vaccination or immunization.

Process To Be Followed In Planned And Unplanned Hospitalization

In case of a planned authorization, all non-emergency hospitalization situations require prior authorization from the Help Desk. This is done to guarantee that the insured member receives the best treatment available and is not inconvenienced when seeking admission into a Network Hospital.

You must get hospital admittance after your hospitalization has been pre-authorized. Raksha TPA will give the hospital a letter of credit or a cashless approval letter. Please provide your government-issued and health ID cards at the hospital entrance desk. In the event of a network hospital, the insured member is not needed to pay the hospitalization bill. The invoice will be issued to and paid for by Raksha TPA, but the employee or patient must cover any disapproved amounts.

However, in case of an unplanned hospitalization, employees can get up to seven days before the entrance to request cashless approval. The cashless authorization form is accessible at the hospital's TPA assistance desk. When visiting TPA, the employee must have TPA Card and a valid ID. Once the hospital has given you all the necessary information, it takes no longer than three hours to approve cashless claims.

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What to do and Not for HR while managing GMC/GPA policies?

Employee satisfaction is a crucial aspect affecting an organization's productivity. It significantly affects how a firm grows and maintains its competitiveness. Taking care of the employees is the basic task of HR. they do everything they can to make their employees happy and safe in the office environment. Employers provide a range of perks, such as preferred leave and insurance, to keep workers happy and motivated.

The two most prevalent insurance plans offered by employers to insure their employees are group medical coverage (GMC) and group personal accident insurance (GPA). These plans aid companies cover the costs of unlucky workplace accidents. Both these policies guarantee the employees' welfare by providing them with financial and medical coverage.

What is a GMC insurance policy?

A sort of health insurance called a Group Medical Cover, or GMC, is for a group of people, such as the staff of a single company. It also extends to their dependents, such as their spouse, kids, and parents.

Typically, an employer provides such a policy as a perk and pays the premium. The costs for this type of health insurance are kept cheap since the risk is shared among a large group of people who are already covered.

What does GMC cover?

In the event of a longer than 24-hour admission, hospitalization costs are paid.
It covers costs incurred before and after hospitalization, such as X-rays, medical reports, and medication costs.
It provides immediate coverage for pre-existing conditions like diabetes, hypertension, etc.
The policy may provide coverage for serious conditions like cancer and cardiovascular problems.
In addition, there is coverage for prenatal costs and newborn baby medical costs.
Additionally, GMC covers may offer the option to select add-on covers for a modest additional fee. Maternity insurance, personal accident insurance, and AYUSH treatment insurance are popular add-ons.
Additionally, childcare procedures and outpatient medical services are frequently covered by a GMC.

A Group Mediclaim Insurance is applicable only if the below-mentioned criteria are followed:

They occur in India and are covered by the policy's time frame.
Hospitalization costs for a minimum of 24 hours are allowable.
If a covered member chooses a room with a higher rent category than what is allowed for him, the corresponding deductions will be made.

What is a GPA insurance policy?

A type of insurance called group personal accident insurance (GPA) covers a group of people financially in the event of unanticipated incidents that cause death, serious injury, or disability.

Accidents can happen at any time and have unanticipated negative effects on your health. Therefore, GPA insurance has some built-in provisions to protect employees if an accident results in their death or a handicap that affects their ability to earn a living. It offers them or their families some level of financial security.

What is a GPA cover?

It offers financial protection if an accident results in partial, total, or permanent disability (such as the loss of limbs or vision).
In the worst-case scenario, it offers dependents financial security.
Ambulance and transportation costs are also offered as an optional benefit.
When hospitalization costs are related to an accident, it covers things like room rent and daycare visits.
In the event of death or permanent disability, it pays for specific benefits for dependent children, such as college tuition or wedding expenditures.

The employees must enroll themselves to obtain coverage for themselves and their eligible dependents. The HR should collect relevant enrolment data like Employee ID, Name, Date of Birth, Gender, Relationship, etc., they have to make sure that the data is relevant and valid and thereafter submit the details to the insurer. The employee's data must reach the insurer within 30 days of their joining. Employees also have to inform HR whenever they need to get a new dependant added to their policies, like in case of marriage, birth, or adoption of a child. All this information has to be submitted to the insurer within 30 days of the process.