What are general exclusions under group health insurance?

Group health insurance is vital for employer-employees susceptible to multiple health conditions. Group health insurance policies cover all members in the group, regardless of their medical history or health status. This means that you and your family will be treated equally and receive the same quality of care, no matter who you are. 

Giving Season 3 GIF by The Simpsons

However, a few exclusions typically apply to group health insurance policies. This blog explores these exclusions and how they can impact your coverage. So whether you’re looking for protection from unexpected medical expenses or want to know what’s not covered by your policy, read on!

Why is group medical health insurance important? 

Group health insurance can provide peace of mind in knowing that you’re covered in an illness affecting your loved ones. Group insurance offers comprehensive and affordable coverage for a family or group of people. It’s also great for covering preventive care, such as screenings and checkups, which can save you money in the long run. Make sure to get the right policy for you and your loved ones, and don’t forget to take advantage of the benefits that group medical cover can offer. 

General exclusions under group health insurance 

If you’re looking for group health insurance, it’s essential to know the exclusions that are typically included. These exclusions can vary depending on the plan, so be sure to speak with an expert to understand what’s covered. If you fall under one of the mentioned categories, your coverage may be limited or non-existent: accidents, chronic illnesses, and pre-existing conditions. 

Pre-existing medical conditions 

If you have pre-existing medical ailment/illness/conditions, knowing they will not be covered under group health insurance is essential. The insurance company may deny you coverage if you are a high-risk individual. There are long lists of exclusions, some of which can be pretty serious – like major illnesses or those which would result in the insured person’s death. Moreover, maternity cover will also be discontinued once pregnant women become members of the policy plan. 

Alternative treatments 

Alternative therapies can be an interesting addition to health insurance plans. However, before enrolling in one, it is important to understand what treatments are covered and which ones are not. Also, note that these alternative treatments may not be affordable for everyone. If you want alternative therapies included in your coverage, make sure to talk to your insurance provider first. Alternative therapies such as homoeopathy, acupuncture and naturopathy are generally not covered under group health insurance plans.

Lifestyle-related conditions 

  • Smoking 
  • Mental illness 
  • Obesity 
  • Alcohol abuse 
  • Diabetes – Type 2
  • Unhealthy living
  • Narcotics abuse
  • Anxiety and stress
  • Hypertension

Cosmetic treatments 

Most group mediclaim insurance plans do not cover cosmetic treatments. Out-of-pocket expenses for cosmetic procedures will range from INR 50,000 to several lakhs of rupees, depending on the type of treatment and where it is performed.

Pregnancy and childbirth 

Pregnancy and childbirth are undoubtedly life-changing events. However, you will have to pay for these services yourself. This means that even if your employer offers maternity leave benefits, you won’t be able to take advantage of them as they aren’t considered group health insurance exclusions. 

After childbirth, many women are advised not to conceive again for a specific period of time to ensure the health & safety of both mother and baby. You must seek medical advice before making any decisions regarding conception or childbirth; otherwise, you may experience complications or lost fertility due to past surgery or illness. 

Maternity insurance cover/leave policies vary from company to company; however, in most cases, it’s advisable to claim to leave within 12 months of giving birth to avoid losing out on its benefits. 

Diagnostic expenses and reports

You may have to pay for a few diagnostic expenses if you are covered under group health insurance. These include doctor’s fees, lab tests, and x-rays. You might be required to pay for medication prescribed by the doctor. 

Dental, hearing, and vision 

When it comes to dental, hearing, and vision services, most people are unaware that group health insurance policies don’t cover them. In addition to this, certain conditions can also exclude you from coverage. For example, mental illness might mean you’re not eligible for dental or vision care. 

Despite all these things being true in many cases, there are a few ways in which you might be able to get medical coverage for your needs despite the lack of insurance on your part. You could have a high-deductible plan or an employer who offers comprehensive health benefits, including dental and vision care, as part of their package. 

Injuries caused due to suicide attempt/self-inflicted harm

It is essential to know that group health insurance does not typically cover injuries or illnesses caused by suicide attempts. In addition, cancer treatment and mental illness are also not usually covered unless they are considered pre-existing conditions. If you have ever been injured/hurt as a result of someone attempting suicide, you may be able to receive compensation from the individual or organization responsible for the attack. 

Waiting period clause 

If you have a pre-existing condition/illness/ailment, your group health insurance may not cover all of your treatments until the waiting period has passed. This waiting period clause is an exclusion that applies to medical services required for a pre-existing condition. 

Make sure you understand what is not covered before purchasing group health insurance. It allows the insurance company to deny coverage for these services without waiting for the necessary treatment. 

Permanent exclusions 

It is essential to know that there are certain circumstances in which your insurance policy does not cover you. These include pre-existing conditions, maternity leave, newborn care and time away from work for illness or injury. 

In addition, being fired from your job due to an illness or injury does not count as a covered event, and you will not be compensated. Finally, coverage does not extend beyond the borders of your country while on vacation with your employer – whether it is part of your regular work schedule or not – unless the trip lasts at least 3 months and takes place overseas under company policies. 

Frequently Asked Questions

Can I still be covered if I go through a divorce? 

Yes, you can still be covered under your group health insurance if you go through a divorce. The most common exclusions for group health insurance when someone goes through a divorce are due to pre-existing conditions and being married to the person with the illness. However, it is always best to speak to an insurance provider and clearly understand what the policy covers before making any decisions. 

Conclusion

Group health insurance is a valuable insurance policy that can provide you and your family with essential health benefits. While it covers various health-related expenses, specific exclusions may apply. Please read our blog to learn about the most common general exclusions under group health insurance and ensure you know them before deciding on group mediclaim.

Tweet to Plum.

Author

Growth Marketing at Plum Insurance