Coverage Of Group Health Insurance Scheme And Exclusions Of Claim
Coverage Of Group Health Insurance Scheme And Exclusions Of Claim.Group health insurance can be defined as a type of health insurance policy where the policy of insurance is given to a particular group of people such as employees of a company or members of certain association. There are several advantages to this type of insurance for employers and employees which includes; cost saving, total health care cover and tax incentives. Yet, it’s good to note that like every form of insurance policy, one needs to know the coverage provided and what is not covered to avoid being caught off-guard when making claims.
It is apparent from the above sharing that Group Health Insurance has the following meaning:
Group health insurance can therefore be described as policy that covers a number of people under one plan. This specific insurance is sometimes offered as part of package offered by employers, whereby companies cover part of or the whole premium. In some instances, the companies that are involved in a particular line of business may also provide group health insurance to the professional associations or organizations, which their members belong.
These policies entail medical bills, hospital, surgeries and other treatments more effectively cheaper as compared to individual health insurance. Another benefit that is related with the group health insurance is that one can include the other family members or dependents without necessarily paying an extra amount of money.
Situation Physician and Surgeon in Connection with Group Health Insurance Plans
This policy comes in different DC and depending on the particular Underwriters undertaking to provide the cover. However, most plans offer the following standard coverages:However, most plans offer the following standard coverages:
1. **Hospitalization Expenses**
– Hospitalization feature can be regarded as the essence of the group health insurance. This Health care expenditure incorporates Hospital care costs, which is the amount that one would spend in a hospital charge per admission, per day admission rate, cost of nursing, doctor’s fees, ICU, and drugs given to a patient during the period of admission. It covers both the scheduled appointments and the accidents that may arise hence employees do not have to be worried over their bills while in the hospital.
2. **Pre- and Post-Hospitalization Expenses**
– Pre and post hospitalization expenses are costs that most group health insurance policies will cater for, these are costs that are incurred 30 days before and 60 days after admission. This comprises of tests, checkups, and prescribed drugs needed as the patient heals from the ailment.
3. **Day Care Procedures**
– A significant number of medical procedures do not have to be admitted in a hospital for 24 hours, including chemotherapy, dialysis and cataract surgery. Most group health insurance plans provide for these day care procedures, to provide convenience to those, who require small scale treatment, which does not require hospitalisation.
4. **Maternity and Newborn Care**
– Depending on the specific contract some group health insurance offer cover host maternal charges for example prenatal care and expenses for delivery and postnatal care. Closely linked to this is that many policies also begin immediately after birth thus providing adequate cover for both the mother and the child. However maternity benefits are offered with a waiting period ranging from as low as nine months to as high as twenty-four months before coverage is effected.
5. **Critical Illness Coverage**
– Group health insurance policies offer benefactors protection in case of contracting critical illnesses for example cancer, heart diseases, kidney failure and stroke. These illnesses call for special and in most cases costly remedies. Critical illness coverage offer a one-off payment or additional months of cover to assist with these expenses, the financial pressure on the employees does not have to be as great.
6. **Accidental Coverage**
– You may also have unexpected accidents, which translates to large amounts of medical bills. Most group health insurance plans have provision for accidental injury which guarantees the employees medical attention in the event of an accident, surgery and post-surgery treatment and physiotherapy.
7. **Pre-Existing Diseases**
– While with the individual health insurance, it is rare to get coverage for pre-existing diseases in the policy except for options offered under the group health insurance policy. Diabetes, hypertension and cardiovascular diseases for instance may be taken care of as soon as one joins an insurance program without any waiting period or time limit.
8. **Mental Health Coverage**
– Some of group health insurance policies provide benefits cover for mental health services since the health of a person’s mind is as vital. This may involve going to see a psychiatrist, a psychologist, taking therapy sessions or seeking treatment for illnesses such as depression and anxiety.
9. **Ambulance Charges**
– Hire emergency transportation: costs incurred in hiring an ambulance in case of a medical emergency are also catered for most group health insurance policies. This is helpful to the employees to enable them to access the medical facilities to seek medical treatment without the added ague of having to worry about the cost of Oklahomans transport.
10. **Health Check-ups**
– Most employer sponsored group health insurance covers yearly preventative health check-ups at no charge or for a small fee. Such measures help each employee to observe the fact of his or her state, identify the commencement of diseases, and act accordingly.
Coverage Of Group Health Insurance Scheme And Exclusions Of Claim
Exclusions in Group Health Insurance Plans
Whereas group health insurance plans offer a broad level of coverage, these plans come with rites omissions. With regard to the policy exclusions, it is always relevant to identify some of them so that the employee has an understanding of what certain situations cannot be covered under the policy.
1. **Cosmetic or Elective Surgeries**
– Employer sponsored group health insurance normally does not cover surgeries that are considered elective or cosmetic in nature that is not required due to medical necessity. Operations that include face lift, that liposuction, hair replacement surgery are normally not covered in the insurance policy unless they have been caused by an accident or an illness.
2. **Self-Inflicted Injuries**
– Self-inflicted injuries or sickness including suicide and attempted suicide are normally not covered. This also comprises of sicknesses that are as a result of involvement in risky exercises or reckless actions.
3. **Creditor’s Illness During The Waiting Period
– While some of the insurance policies being offered by the groups are those that have no waiting period and do not exclude pre-existing diseases, others have a waiting period of between one to four years in which the insurance company will not entertain any claims of pre-existing diseases. All these diseases well known to need treatment well have to remain untreated during the waiting period; any treatment sought during this period cannot be paid for.
4. **Substance Use Disorder & Other Related Illness**
– Many group health insurance policies do not cover ailments that are as a result of substance abuse including alcohol and drug addition. The treatment of addiction or the diseases that stem from substance use are usually not paid for by insurance.
5. **War-Related Injuries**
– TIB: Wars, terrorism or military service are other covered conditions that are usually excluded from most group health insurance policies. It also applies to injuries that may stem from nuclear, chemical or biological accidents.
6. **Experimental Treatments**
– This is any treatment or procedures which is not approved medically, or are still a subject of research or not recommended for use. This is similar to treatments that are currently under testing or which are still considered experimental or non mainstream.
7. **Other Modalities of Treatment not coming under AYUSH**
– As we have already pointed out above, any health program that is not under the conventional Allopathic methods of treatment may not be considered under the group health insurance policies even if they are mentioned. But there are some insurers who make AYUSH available as an option for the employees so they can go for the treatments.
8. **Dental and Vision Care**
– Basic care like dental and vision, including a simple tooth clean up, fixing cavities or buying a eyeglasses can be done without involving the group health insurance unless it is included. It is however noteworthy that some insurers offer optional packages for dental and vision at a relatively higher cost.
9. There is also the provision for maternity benefits that are paid to the women employees during the period of waiting.
– On Maternity coverage, depending on the insurance plan taken, it extends coverage after childbirth after 9 months- 24 months duration. Any pregnancy related costs that may be incurred in the course of this waiting period will not be provided.
10. **Congenital Diseases**
– A majority of the group health insurance policies do not include the congenital diseases or birth defects among the conditions to be covered unless a policy holder specifically includes it. This means that any treatment of surgical operation for congenital diseases need not be financed.
How to Choose the Right Group Health Insurance Plan
Selecting the most appropriate group health insurance plan requires the evaluation of the needs of the group and comparing the insurance programs that are offered in the market in relation to the premium rates. Here are some key factors to consider:Here are some key factors to consider:
– **Coverage Needs**: Assess the extent of medical requirements for that group in terms of pre existing conditions, major diseases and maternity benefits. The plan should be inclusive enough without having to exclude so much.
– **Sum Insured**: Make sure that the figure insured per employee is large enough to cater for hospitalization and other treatments as may be required. Medical costs can escalate for some of the serious diseases and hence one has to ensure that the insurance plan offer adequate cover.
– **Add-On Benefits**: Secondly, look for additional freebies attached to the policy like free wellness check up and plans to avail coverage for AYUSH which are additional benefits which can make the policy even more valuable.
– **Network Hospitals**: In this regard, it is important that one chooses an insurance provider that there are many hospitals that accept cashless.’ This enable the employees to be attended to by medical practitioners without having to pay for their services in advance.
Conclusion
Group health insurance is a very important employee benefit whereby organizations provide insurance cover for medical expenses that may occur in the course of the employee’s working life. It is very important to analyze what is and is not included in a group health insurance policy to make good choices regarding the insurance plan. When it comes to selecting a policy, there is a chance to support the employees with healthcare needs and, at the same time, sustain the employers’ financials with high costs of medical insurance.