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What Group Health Insurance Doesn't Cover: Key Exclusions You Must Know

 

Many employees covered under a group health insurance policy are under the impression that this policy will cover any cost they incur for illness or hospitalization. But the fact is the insurance cover by a group health insurance policy has several exclusions which employees discover much later.

Due to these exclusions, an employee who has to undergo medical treatment might not get the required coverage due to exclusions, which can cost him financially and emotionally.

Employees need to be aware of what is not covered in a group health insurance policy so that when medical treatment is necessary for them or their family members, they know whether coverage is available or not and they can be in a better position by taking a personal health insurance policy.

In this blog, we will focus on exclusions in a group health insurance policy.

What are exclusions in group health insurance?

Exclusions are conditions or treatments that a group health insurance policy will not cover. They are listed explicitly in the policy document, yet most employees don’t feel the need to read them until a claim gets denied.

Apart from these specified ones there are certain common exclusions which are not covered under group health insurance such as congenital diseases, HIV, AIDS, injuries due to war, natural calamities or disasters.

Understanding these exclusions will help employees understand the limitations of the coverage.

Common exclusions in group health insurance policies 

 OPD (Outpatient Department) expenses

Doctor consultations, diagnostic tests, and medicines outside of hospitalization are rarely covered under group policies. These expenses have to be borne by the employee.

Cosmetic or aesthetic procedures

Group health insurance won’t pay for cosmetic or aesthetic procedures unless they’re medically necessary (like after an accident).

Weight loss treatments

Group health insurance won’t pay for weight loss treatments like, bariatric surgery, botox, etc.

Vision loss treatments

Group health insurance won’t pay for vision loss treatments like IOL , etc.,  unless they’re medically necessary (like after an accident). Cataract is normally covered but shall be subjected to sub limits specified 

Alternative treatments

While some policies now include Ayurveda, Homeopathy, or Unani under AYUSH, coverage is often limited or completely excluded. The coverage for these alternative therapies varies between insurance companies. Some insurance companies may cover these treatments with specific limits.

Dental and vision care

Routine dental cleanings, braces, spectacles, or LASIK are not covered, but some employers can offer comprehensive healthcare benefits and include such benefits in their group health insurance policy.

Diagnostic tests

Blood tests, scans, pathological tests, are not covered under group health insurance  unless they are required as part of the treatment or hospitalization for a condition covered under the policy.

 Self-inflicted injuries and substance abuse

Injuries or illnesses resulting from suicide attempts, drug abuse, or alcohol abuse are usually excluded. Even if there is hospitalization, the insurer may reject the claim. Mental illness is not covered unless it is a pre-existing condition.

Know the exclusions

The exclusions in a group health insurance can create gaps in health insurance coverage that can cause a lasting impact on an employee’s finances. While an employer may upgrade the policy annually, employees cannot totally rely on a group health insurance policy to cover their medical expenses.

Employees should know about the exclusions in the group health insurance policy provided by their employer to avoid nasty surprises when dealing with medical emergencies or health conditions. They can:

·       Ask for the policy brochure from HR and read the exclusions section carefully.

·       Check for sub-limits on room rent, ICU charges, and specific treatments.

·       Supplement with individual health insurance to plug coverage gaps.

 

Employers on their part should review the group health policy every year to ensure better benefits for employees such as enhancing maternity benefits, providing mental health support or OPD coverage.

It is best to consult an insurance broker when choosing a group health insurance policy that will provide employees with comprehensive health benefits.

We at Zen Insurance brokers assist in choosing a health insurance policy with clauses suited to your requirements. Choose your insurance policy wisely. Get in touch with us for any assistance.

 

Disclaimer:

Zen Insurance Brokers is an IRDAI registered broker which facilitates quick and adequate insurance broking services. We deal with only regulator approved products of insurers. We do not underwrite the products.

 

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