Employee Benefit Insurance for Indian Companies

Typically, coverage extends to the employee, spouse, and dependent children (usually up to age 25). Many policies also allow for the optional inclusion of parents/parents-in-law of the employee at an additional premium.

ESI is a statutory, contribution-based social security scheme for low-wage employees (salary threshold applies). Group Health Insurance is a commercial insurance product purchased by the employer, offering more flexibility in sum insured, network hospitals, and coverage features. Companies may need to comply with both depending on their workforce.

For planned hospitalization, contact the TPA/insurer for pre-authorization. For emergencies, inform within 24 hours of admission. The hospital sends the pre-auth form to the TPA. Once approved, the insurer settles bills directly with the hospital, subject to policy terms.

Yes, but typically after a waiting period, which is commonly 2 to 4 years of continuous coverage under the policy. The specific waiting period is defined in the policy wording. Portability from a previous insurer can credit the served waiting period.

While not universally mandatory, various state-specific Shops & Establishment Acts require employers to provide medical benefits. It becomes de facto mandatory for competitive talent retention, contractual obligations with clients, and for companies exceeding ESI thresholds wanting to offer better coverage.

Premium depends on multiple factors: number of employees and dependents, their age profile, sum insured chosen, industry type, location, past claims history, and add-ons selected. It is typically quoted as a total annual premium for the group.

Yes, as per IRDAI portability guidelines, an employee has the right to port their individual health cover (along with dependent coverage) to another group policy or an individual policy, provided continuous coverage is maintained and application is made 45 days before renewal. Credited waiting periods for PED also port.

Common exclusions include suicide, self-inflicted injury, war/invasion, nuclear risks, influence of intoxicants, and injuries from hazardous activities unless specifically covered. Always refer to the policy wording for the complete list.

For the employer, premiums paid are generally treated as a business expense. For employees, the value of premium paid by the employer for health insurance up to Rs. 15,000 and for Accident/Death benefit is a tax-free perquisite as per the Income Tax Act. Employees should consult their tax advisor.

Yes, most insurers allow for a tiered or graded sum insured structure (e.g., junior staff, middle management, senior leadership). This is a common and efficient way to align coverage with needs and manage costs.

Coverage typically applies from the date of joining as per the policy, irrespective of probation, unless the policy has a specific waiting period for new joiners. It's crucial to add new employees to the census list and inform the insurer as per the policy terms (monthly/quarterly).