Understanding the Eligibility for Group Health Insurance

Group health insurance has been one of the greatest gifts from the insurance industry in today’s uncertain times. For one, these coverage plans involve minimum costs from the covered individuals. As these insurance plans are purchased and provided by companies, they also leave the insured out of the ambit of undergoing documentation and other processes for availing of health coverage. It provides an amazing opportunity for employers to provide basic medical care to the working class. Nevertheless, not all organisations can provide this facility to their employees.

As such, it is essential to know about the aspects qualifying which make a company, organisation or group eligible to provide group health medical insurance coverage to their employees or members. We thus bring a guide that shall help identify a company’s eligibility for providing group health coverage.

Group Health Insurance Eligibility Criteria

The Insurance Regulatory and Development Authority of India lays guidance regarding the eligibility criteria for providing group medical insurance coverage. However, registered organisations across a wide ambit fall in the category of eligible groups for providing group medical coverage to their members. Some of the identified registered groups, organisations or institutions include the following.

• Small organisations
• Large organisations
• Emerging startups
• Social associations
• Cultural associations
• Any other registered group with a common interest

As for the minimum number of members or employees these identified groups must have to be eligible to provide group mediclaim coverage is specified as 20. This means that any such group with a member count under 20 cannot provide such coverage to their members.

However, with the emergency of many small organisations with less than 20 members under them, the need to provide such coverage to members of these institutions has been recognised, too. Consequently, IRDAI has amended the eligibility rules to bring these institutions under the ambit of such coverage.

Following this amendment, companies or groups with a member count of less than 5 are now eligible to provide micro-insurance plans for health coverage. Hence, now companies, organisations or recognised groups can also offer group health insurance to their members or employees effectively for easy, private healthcare coverage.

With respect to the standard minimum member count requirement of 20, it is also interesting to know another rule. While the minimum member count for such institutions/groups is 20, it need not necessarily comprise employees/members only. That is to say, even the dependent family members of such an employee included as policy beneficiaries will be added to this count.

Exclusions to Group Mediclaim Coverage

Along with the eligibility requirements, one should also know about the groups or organisations excluded from the list. Thus, the groups/organisations who cannot provide group health insurance to their members include the following -

1. Family business

In the case of a family business where the only member under the organisation is the spouse, such a spouse will not be considered an employee for the purpose of providing group health coverage.

1. Sole entrepreneurs

In this case, entrepreneurship comprises only the sole entrepreneur. Such a person will not be considered an employee of the self.

1. Dependents

In some cases, dependents of the employee or member can be added as beneficiaries under the policy, but only at an extra premium cost. As such, they are excluded from eligibility unless such a contribution is made.

Why Should Organisations Provide Group Health Insurance?

An innovative solution to extend health insurance coverage to the masses at low cost, group health insurance policies have increased the outreach of health coverage. Thus, the primary purpose of providing this type of health coverage is to make private healthcare affordable for the salaried class. Several general insurance companies in India provide group health insurance policies.

As these policies cover a wide range of generic illnesses, the insured and beneficiary members need not worry about financing the related medical expenses out of their pockets. They can thus resort to making claims under the policy and avail themselves of the best healthcare available for their illnesses at the network hospitals.

The availability of group health insurance has enabled many economically challenged salaried individuals and families to reap the benefits of health coverage. These policies have also made private healthcare accessible for many. Companies and organisations looking forward to providing healthcare coverage to their employees/members, no matter how small, can thus make healthcare affordable for many.