Group Health Insurance: A Guide for Small Business Owners & HR Professionals

For small businesses and HR teams, attracting and keeping talented staff is vital. Offering compelling employee benefits, especially health insurance, is one of the most effective strategies. Group health insurance is a popular choice that allows organizations to provide comprehensive healthcare benefits to all employees under a single policy, simplifying management and reducing costs.

What is Group Health Insurance?

Group health insurance, also known as corporate health insurance, is a policy that covers medical expenses for a collective group of people. Often included as part of employee benefits, it fosters a healthier and happier workforce, boosting productivity. Coverages typically include hospital stays, daycare procedures, maternity care, surgeries, and often extend to employees’ families—spouses, children, and dependent parents.

Who Should Consider Buying Group Health Insurance?

• Small & Medium Enterprises (SMEs): Textile units, logistics firms, food processing businesses.
• Start-ups: Tech companies, app developers, online services.
• Large Corporations: IT firms, manufacturing units, retail giants.
• Associations/Societies: Rural development organizations, social welfare groups.
• Financial Institutions: Banks and similar entities aiming to strengthen client relationships.

Types of Groups Covered

According to IRDAI, a group is a collection of members engaged in a common economic activity, not formed solely for insurance benefits. These can be categorized as:

• Employer-Employee Groups: Companies offering health coverage to employees, with the employer generally paying the premium or making minimal contributions.
• Non-Employer-Employee Groups: Welfare associations, societies, or customer groups (e.g., credit cardholders), where members typically share the premium costs.

Why Do You Need Group Health Insurance?

• Simple Purchase Process: Online assessment, easy policy customization.
• Customer Support: Dedicated guidance at every step.
• Cashless Treatment: Access to over 12,000 hospitals nationwide.
• Broad Coverage: Hospitalization, maternity, daycare, domiciliary treatments, and more.
• Add-Ons: Optional coverage like prenatal care or newborn treatment.
• Hassle-Free Claims: Fast settlement for cashless and reimbursement claims.

How Does It Work?

1. Policy Purchase: Employers evaluate needs and purchase the plan.
2. Premium Payment: Usually paid fully by the employer or shared with employees.
3. Enrollment: Employee and family details are added.
4. Coverage Begins: Employees can access healthcare services.
5. Claims: Employees or employers file claims for treatment.
6. Settlement: Claims are processed and paid.

Benefits for Employers

• Legal Compliance: Mandatory in India post-COVID-19, per IRDAI.
• Talent Attraction: Many candidates prefer companies with health benefits.
• Employee Retention: Boosts morale and loyalty.
• Employee Well-Being: Promotes a healthier, less stressed workforce.
• Productivity Boost: Builds trust and focus.
• Cost Savings: Spreads risk among many, lowering premiums.
• Tax Benefits: Premiums are deductible under Section 37(1) of the Income Tax Act.
• Enhanced Reputation: Demonstrates corporate responsibility.

Employee Benefits

• Affordable Coverage: Often paid entirely or partly by employers.
• Family Coverage: Extend benefits to spouses, children, and parents.
• No Waiting Period: Cover begins immediately, even for pre-existing conditions.
• Comprehensive Services: Hospitalization, surgeries, ambulance, etc.
• No Medical Check-up: No health screening needed, even for older employees.
• Tax Deductions: Employees can claim under Section 80D.

TATA AIG Group Health Insurance Plans: Key Features

Coverage Highlights

• In-Patient Treatment: Hospital stays and medical expenses.
• Pre/Post-Hospitalization: Costs before and after hospitalization.
• Daycare Procedures: Treatments under 24 hours.
• Domiciliary Treatment: Home treatment for over three days.
• Organ Transplant: Covered if hospitalised.
• Ambulance: Emergency transport costs.
• Maternity Care: Childbirth, pregnancy termination, newborn care.
• Family Transport: For hospital stays over 200 km.

Exclusions (What’s Not Covered)

• Investigation and Evaluation expenses not related to treatment.
• Rest and Respite Care.
• Obesity-related surgeries.
• Gender change procedures.
• Cosmetic or plastic surgeries.
• Addiction treatments.
• Unproven medical treatments.
• Dental, refractive errors, adventure sports injuries, infertility, and breach of law-related expenses.

Key Factors to Consider When Choosing a Plan

• Employee needs and demographics.
• Policy inclusions and exclusions.
• Available add-ons.
• Premium affordability.
• Claim procedures and documentation.

Eligibility & Application Process

1. Ensure the group qualifies as per IRDAI’s definition.
2. Assess coverage needs and employee health profiles.
3. Use online calculators or visit branches for offline purchase.
4. Complete the application, pay premiums, and activate the policy.

Filing Claims

Cashless Claims:

1. Notify TATA AIG within 24 hours of emergency/hospitalization.
2. Request pre-authorization at the hospital.
3. Undergo treatment if approved.
4. Submit discharge reports at discharge.
5. Claims are settled directly with the hospital.

Reimbursement Claims:

1. Notify TATA AIG within 24 hours.
2. Get treatment at any authorized hospital.
3. Pay bills and retain receipts.
4. Submit claim form, bills, and documents.
5. Reimbursement is processed after review.

Important Documents

For Cashless Claims:

• Insurance card, ID proof, admission notes, previous medical records.

For Reimbursement:

• Claim form, bills, medical certificates, discharge summaries, receipts, bank details, investigation reports, and other supporting documents.

What is a Health Card?

A health card is an ID issued to insured employees, containing key details like policy number, member ID, and validity. It’s essential for cashless treatment at network hospitals.

Add-Ons Available

• Prenatal & Postnatal Care: Pregnancy and post-delivery expenses.
• Baby Day One Cover: Newborn treatment from birth.

Downloading the Health Card

• Via the TATA AIG mobile app.
• Through email from the employer.

Key Terminologies

• Premium: Periodic payment to keep the policy active.
• Deductible: Amount paid out-of-pocket before insurance coverage applies.
• Copayment: Fixed amount paid at the time of service.
• Network: Hospitals with agreements for cashless treatment.
• Pre-Authorization: Approval process before certain treatments.
• Exclusions: Non-covered services.
• Waiting Period: Time before coverage applies for certain conditions.
• Renewal: Extending the policy beyond its initial term.

Group vs. Individual Health Insurance