Group Medical Cover

Does Your Group Medical Cover (GMC) Need a Group Accidental Cover (GAC)?

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Group health cover or group medical insurance or mediclaim and group personal accident insurance are the two most common employee benefits companies, and organizations provide. This is the reason why both are often confused with each other. Both group accidental cover and group medical cover compensate for the financial burden imposed by medical emergencies.

However, there are several differences between group health insurance and group accidental insurance. A clear understanding of the various features and benefits of group mediclaim and group personal accidental besides specific differences is in order.

What is group medical cover?

Group medical cover provides equal benefits to all the members mentioned in the policy document. As per IRDAI, an organization that employs at least 20 employees is eligible for group health insurance. However, even if the employee strength is less than 20, an organization is eligible for group health insurance provided the family members of the employees are also included in the policy.

A group can purchase group medical cover with a common interest such as employer-employee groups, professional associations, clubs, employee welfare associations, and more. A group cannot be formed specifically for purchasing group health insurance.  

What is included in group medical cover?

Group medical cover covers hospitalization expenses such as room rent, doctor’s fees, cost of medicines, nursing charges, and more. Many group health insurance plans also provide pre and post-hospitalization expenses. Pre-hospitalization expenses include diagnostic tests, doctor visits, and others before hospitalization.

Post-hospitalization coverage is for expenses incurred after discharge from the hospital, such as diagnostic tests to determine the extent of recovery, visits to the doctor, and others. Pre-hospitalization expenses incurred up to 30 days before hospitalization and post-hospitalization expenses for up to 60 days post-discharge are covered.

Family, including parents and spouses apart from dependents, can also be included in the group medical insurance policy. 

Individual health insurance plans have waiting periods for covering pre-existing conditions. Pre-existing diseases are covered by group medical cover without any waiting period. In the case of group health insurance, the pre-existing diseases are covered from day one. A wide range of specific illnesses is also covered by group medical cover.

Group medical cover provides maternity coverage as an add-on benefit. This coverage compensates for the expenses incurred on both normal and C-section deliveries. Newborn coverage is also provided for medical care of newborn babies for 90 days after birth. 

The group medical cover can also provide coverage for ancillary expenses such as ambulance charges. 

What are the exclusions in group medical cover?

Group medical cover does not compensate for expenses incurred in treating certain conditions such as drug or alcohol abuse and sexually transmitted diseases such as AIDS. Treatment for injuries sustained due to suicide attempts and treatment for mental disorders are also not covered under group health insurance. Furthermore, group medical cover may not cover congenital diseases.

Alternative treatment methods such as homeopathy, ayurvedic, Unani, and others are not covered. In other words, only allopathic treatments are covered by group health insurance. Dental treatments, cosmetic surgery, and gender change surgery are also not covered by group medical cover. 

Infertility treatments, birth control procedures, and surrogacy are not covered under group health insurance. Treatment expenses for injuries sustained during participation in dangerous sports or other activities are also not covered under group health insurance.

What is group personal accident insurance?

Group Personal Accident Insurance is designed to financially help the covered members of a group in an accident resulting in injuries, disability, or death. Group personal accident insurance plans are usually purchased by companies having employees exposed to risks of accidents. 

What is included under group personal accident insurance?

Group personal accident insurance reimburses the cost of hospitalization and treatment cost of injuries sustained due to an accident. An amount is paid to the employee to treat broken bones as well. 

If the covered employee becomes partially disabled due to the accident, an amount which can be 2%-60% of the sum assured under the policy is paid. In case of total disability caused by accident, the compensation amount can even be the entire sum assured.

Educational benefits are provided to the employee’s children if the employee becomes permanently disabled or even dies due to the accident. This means the policy pays for the educational expenses of the children.

Ambulance charges to transport the injured employee from the accident site to the hospital or carry the mortal remains of the employee from the hospital to the residence or funeral grounds are covered.

The sum insured is paid as a lump sum amount to the employee’s nominee in case of the employee’s accidental death.

What are the exclusions of group personal accident insurance?

Injuries sustained while under the influence of alcohol, drugs, or other intoxicants are not covered under group personal accident insurance.

Self-inflicted injuries or injuries caused due to involvement in illegal activities are not included in group personal accident insurance.

Injuries or death caused due to pregnancy, childbirth, or diseases are not covered. Injuries caused by wars, nuclear radiation, and events related to violation of laws are also not covered under group personal accident insurance.

The death benefit under group personal accident insurance applies only to accidental deaths. Natural deaths do not qualify for the death benefit.

What are the differences between GMC and GPA?

Group medical cover is a comprehensive plan to cover the employees’ medical expenses arising as a result of diseases or injuries. Group Personal Accident Insurance, on the other hand, is concerned only with accidental injuries and mainly focuses on providing compensation for disability or death.

Group medical cover can be extended to the family members of the employees as well. Group Personal Accident Insurance is limited to the employees only.

Group medical cover ceases to function outside the geographical limits of the policy. Group Personal Accident Insurance provides benefits regardless of the geographical location of the accident.

Conclusion

Both group medical cover and Group Personal Accident Cover are beneficial for the employees. It is better to provide both kinds of covers to the employees to maximize their benefits over and above their salaries.

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