Group Health Insurance Glossary

An IRDAI-licensed intermediary who represents the client (employer), not the insurer. Brokers compare plans across multiple insurers, negotiate premium and terms, manage renewals, and support claims throughout the policy year. SecureNow Insurance Broker Pvt. Ltd. is an IRDAI-registered Direct Broker (Certificate No. 425).

A claim where the insurer or TPA settles the hospital bill directly with the network hospital. The employee does not pay upfront. Cashless treatment requires pre-authorisation from the TPA for planned admissions. In genuine emergencies, cashless can be availed without prior approval.

A clause requiring the employee to pay a fixed percentage of each claim amount (e.g., 10-20%) while the insurer covers the rest. For example, a 10% co-pay on a Rs.1 lakh claim means the employee pays Rs.10,000. Zero co-pay policies are available and recommended for employee GMC coverage.

An amount the policyholder must pay before the insurer starts covering a claim. Less common in base GMC policies but frequently appears in top-up and super top-up plans. For example, a Rs.3 lakh deductible means the insurer only pays claim amounts above Rs.3 lakh.

A formal amendment to an existing policy document. In GMC, common endorsements include adding a new joiner, removing a resigned employee, correcting data errors (name, date of birth), or updating dependant details. Endorsements take effect from the date approved by the insurer.

A government-run social insurance scheme mandatory for organisations with 10 or more employees earning up to Rs.21,000 per month. ESI provides health and disability coverage but has limitations - restricted to ESI hospitals, fixed benefits, and no family floater. Many employers offer GMC in addition to or instead of ESI for higher-earning staff.

A policy where the sum insured is shared across all insured family members (employee, spouse, children). If one family member uses Rs.3 lakh of a Rs.3 lakh floater, nothing remains for others in that policy year. Individual policies allocate separate sum insured to each member.

An association of public sector general insurers (New India Assurance, Oriental Insurance, United India, National Insurance) that negotiates standard package rates with hospitals for common procedures and surgeries. GIPSA-empanelled hospitals charge pre-agreed rates, eliminating billing disputes. These rates are lower than private insurer cashless rates.

A single insurance policy that covers all employees of an organisation and their eligible dependants against hospitalisation expenses. GMC is also called Group Health Insurance or Employee Health Insurance. Key advantages over individual policies include no waiting periods for most conditions, pre-existing disease coverage from day 1, and lower per-employee premiums due to group pricing.

The ratio of total claims paid by an insurer to total premiums collected, expressed as a percentage. An ICR of 80% means Rs.80 was paid in claims for every Rs.100 collected in premium. Insurers use the group's ICR at renewal to decide whether to increase or decrease the premium. A high ICR (above 100%) typically leads to significant loading at renewal.

An add-on coverage that pays for normal delivery, caesarean delivery, and pre/post-natal expenses. Subject to a waiting period (typically 9 months from policy inception) and a sub-limit per delivery. Newborn cover - from day 1 of birth - is often bundled with maternity benefit.

A hospital that has a cashless agreement with the insurer or its TPA. Employees can receive cashless treatment at network hospitals without paying upfront. Hospital network size varies by insurer - ranging from 6,000 to 14,000+ facilities across India. Always verify network status before a planned admission.

Medical consultations, diagnostic tests, and prescriptions where the patient is not admitted to a hospital. OPD cover is not included in the base GMC policy and must be added as a separate rider. OPD wallet plans start from approximately Rs.500 per employee per year for a Rs.5,000 annual limit.

The complete legal document defining every term of the insurance contract - what is covered, what is excluded, claim filing procedures, definitions of key terms, and conditions for renewal. Policy wordings are approved by IRDAI and are the binding contract between insurer and policyholder.

Medical expenses incurred after discharge from hospital that are directly related to the same illness or injury. Typically covered for 60-90 days after discharge in GMC policies. Eligible expenses include follow-up consultations, medicines, and diagnostic tests.

Approval sought from the TPA before a planned hospitalisation to confirm cashless eligibility and approve the estimated treatment amount. The TPA reviews the request and responds within 1-4 hours. Pre-auth is mandatory for planned admissions but can be sought within 24-48 hours for emergency admissions.

Any illness, condition, or injury that existed before the policy start date. In individual health insurance, PEDs typically have waiting periods of 1-4 years. In GMC policies, PEDs are usually covered from day 1 - this is one of the most significant advantages of group health insurance over individual policies.

Medical expenses incurred before hospital admission that are directly related to the illness for which hospitalisation subsequently occurs. Typically covered for 30 days before the admission date. Eligible expenses include consultations, diagnostics, and medicines related to the diagnosed condition.

The amount paid by the employer (and sometimes employee) for GMC coverage. Group premium is calculated based on the employee age profile, sum insured chosen, group size, claims history (ICR), industry type, and add-ons selected. Premium is typically paid annually and is tax-deductible for the employer under Section 37(1) of the Income Tax Act.

A claim where the employee pays the hospital bill out of pocket and then submits documents to the insurer or TPA for repayment. Reimbursement claims can be filed from any hospital - not just network hospitals. Documents must typically be submitted within 30 days of discharge.

A sub-limit on the category of hospital room the insured can occupy (e.g., single AC room, shared ward). If the insured occupies a higher-category room, proportionate deductions apply - not just to room rent but to all associated expenses including surgeon fees, nursing charges, and consumables. This can reduce the effective claim payout by 30-50%.

A cap within the overall sum insured that applies to specific conditions, procedures, or expenses. For example, a Rs.50,000 sub-limit on cataract surgery means the insurer pays a maximum of Rs.50,000 regardless of the total sum insured or actual expense. Common sub-limits in GMC include maternity, cataract, and specific disease caps.

The maximum amount the insurer will pay for all claims in a single policy year. In GMC, sum insured is typically provided on a family floater basis (shared across employee and dependants). Common GMC sum insured options range from Rs.1 lakh to Rs.10 lakh per family. The right sum insured depends on city tier, family size, and healthcare cost benchmarks.

An IRDAI-licensed intermediary appointed by the insurer to administer health insurance claims. TPAs manage cashless pre-authorisation, employee e-cards, claim processing, network hospital coordination, and grievance handling. The three largest TPAs for corporate GMC in India are Medi Assist, FHPL, and Vidal Health.

The duration an employee must wait before a specific condition or benefit becomes covered under the policy. Individual health insurance policies typically have 30-day initial waiting periods, 1-2 year waiting periods for specific diseases, and 4-year waits for pre-existing conditions. GMC policies waive most of these waiting periods - another key reason why group coverage is superior for employees.