Your employees are the greatest asset of the company, and your people are its product’.
– Sir Richard Branson, Founder, Virgin Group. In a day and age when employees are difficult to retain, employers are looking for innovative ways to ensure their workforce stays with them. One of the best ways to protect the interest of the employees is by covering them under group employee insurance.
These group health insurance policies cover a plethora of healthcare benefits and a wide range of coverage. But they are not without their caveats.
It is why having a single group plan is often not adequate for most employees, and they often go for an additional plan, such as group term life insurance.
As for employers, they need to ensure they understand the exclusions well before offering a group plan to their workforce.
This article discusses the several exclusions in group employee plans.
Exclusions Under Employee Insurance
While buying group insurance for your employees, it is vital to refer to the ‘Inclusions and Exclusions’ section of the policy document to ensure you know what you are signing up for.
Exclusions refer to conditions that insurance policies do not cover. Most healthcare plans are devised with a specific list of pre-conditions that act as exclusions. It means these plans do not cover financial benefits pertaining to the medical treatment or hospitalization for any of the mentioned exclusions.
The list of exclusions depends on the insurer and the insurance plan you choose for your employees. While the exclusions can be any, it is vital that your workforce is well aware of what is covered and what is not. It would help them mitigate the financial constraints by getting an additional policy, if required, and also ensure a smoother claim process.
Following are some common treatments and diseases which usually form part of exclusions under the group employee insurance:
Group insurance plans do not cover certain permanent conditions. These include genetic disorders or chronic diseases that are often life-threatening. In addition, every insurer has a specific list of permanent exclusions for each policy type.
Pre-existing diseases or PEDs
Group employee plans also exclude certain pre-existing diseases or medical conditions existing before policy activation. While the list may not be long, it is vital for the policy buyers to know about the PEDs excluded.
Cosmetic or aesthetic treatments
Globally, millennials are making mental peace and body confidence their top priority.
According to a survey, the global aesthetic medicine market is expected to grow by 9.5% CAGR from 2022 to 2030 to reach a valuation of USD 83,875 million. It is because many people are spending more on beauty and cosmetic treatments to prevent aging or to feel youthful.
However, these treatments are for personal confidence and satisfaction and cannot be termed ‘medical illness’. Therefore, your employees cannot claim insurance benefits on these.
Self-inflicted injuries/intentional harm
Due to the hazardous nature of their business, some companies may prefer to go for group personal accident insurance. These insurances include cover from accidental injuries or disability risks.
However, if the act is intentional, your employees cannot label it as ‘accidental’. Therefore, suicide or self-harm acts are generally not within the scope of insurance.
Sexually transmitted diseases (STDs) or venereal diseases, like HIV and AIDS, endanger the insured’s lifespan. Therefore, your corporate insurance policies will not cover them. Certain psychiatric, psychological and mental disorders of neurodegenerative nature also come under the exclusions of the insurance policies.
Indulging in a criminal act is not justifiable in a court of law. Therefore, injuries resulting from criminal acts are also not justified, and the insurance company will reject such claims.
Certain family members
One of the primary benefits of a group health plan is that it covers the dependents of the employees like spouses and children. Some companies may extend the policy benefit to dependent parents.
However, if the employees want to cover their other family members, like in-laws, that may not be possible.
Specific AYUSH-related constraints
Traditional treatments like Ayurveda, Homeopathy and Yoga are a prominent part of Indian culture and are considered an alternative system of medicine.
In 2014, the government introduced the AYUSH mission. It includes Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy treatments. The Insurance Regulatory and Development Authority of India (IRDAI) also directed general insurance companies to include AYUSH treatments in their insurance policies.
But here are some exclusions under the AYUSH cover:
- Pre and post-hospitalization expenses
- Treatment or hospitalization outside the government-approved list of hospitals and centers.
- Regular evaluation or health check-ups
- Rejuvenation or preventive treatments not classified as medical treatment.
In addition to the medical cover, the group medical policy offers benefits like maternity care and rent. However, there may be a limit on the room rent. There may be restrictions on the type of rooms also. Therefore, it is necessary to read the terms and conditions carefully.
Further, the insurance policy will cover the pre-and post-hospitalization treatment. However, it won’t cover any consumables or food bills ordered in the room. These expenses are unrelated to the treatment and, therefore, excluded from the insurance cover.
Adventurous sports like scuba diving, skydiving, war and military activities are life-threatening. Therefore, these activities are usually outside the insurance’s purview.
In most cases, employee insurance policies do not cover every health condition that you may expect them to. In addition, the list of exclusions varies with each insurance company and their plans. Therefore, review the terms and conditions carefully and ask in case of any doubts.
You can provide the option to purchase additional insurance coverage for any critical illness not covered by the policy to your employees.
At Plum Insurance, our employee health insurance plans do not have a waiting period, a limit on room rental or a disease exclusion. Further, we have additional super top-up plans which extend the existing coverage hassle-free.
Go through our group employee plans and choose the most suitable one for your workforce.