What Does a Group Health Insurance Policy Typically Cover in India?

Group health insurance covers a defined set of medical expenses under one master policy issued to an employer. While exact inclusions vary by plan, eight categories are typical across most Indian group plans in 2026.

1. In-Patient Hospitalisation

The core benefit. Covers room rent, ICU charges, surgery, anaesthesia, blood, oxygen, doctor and consultant fees, and diagnostic tests during a hospitalisation of 24 hours or more. Most group plans cap room rent as a percentage of sum insured (typically 1-2%) or specify a single private room without sub-limit in higher-tier plans.

2. Pre-Hospitalisation Expenses

Medical expenses incurred up to 30 to 60 days before admission — including diagnostic tests, doctor consultations, and prescribed medication directly related to the hospitalisation. Standard period is 30 days; comprehensive plans extend to 60 days.

3. Post-Hospitalisation Expenses

Recovery-related medical costs incurred up to 60 to 90 days after discharge — follow-up consultations, medicines, physiotherapy, and tests. Standard period is 60 days; higher-tier plans extend to 90 days.

4. Day-Care Procedures

Procedures that don't require a 24-hour hospital stay due to advances in medical technology — cataract surgery, chemotherapy, dialysis, dental procedures requiring anaesthesia, lithotripsy, and dozens of others. IRDAI maintains a list of 150+ recognised day-care procedures; most group plans cover all listed procedures.

5. Pre-Existing Diseases (PED)

Conditions diagnosed before policy inception — diabetes, hypertension, thyroid disorders, asthma, heart conditions, cancer in remission, kidney conditions. Group plans typically cover PEDs from Day 1 with no waiting period, unlike retail policies which apply up to 36 months under the IRDAI Insurance Products Regulations, 2024.

6. Maternity Benefit

Pregnancy-related expenses including pre and post-natal care, normal delivery, C-section, and newborn cover. Sub-limits typically range from ₹25,000 to ₹1,00,000 per pregnancy. Group plans usually waive the 9 to 24-month maternity waiting period that applies in retail policies. Newborn is automatically covered from Day 1 of birth in most group plans.

7. Ambulance Charges

Road ambulance costs from home to hospital, typically capped at ₹1,500 to ₹5,000 per hospitalisation. Air ambulance is rarely covered unless specifically included in higher-tier plans.

8. AYUSH Treatment

In-patient treatment under Ayurveda, Yoga, Unani, Siddha, and Homoeopathy systems at government or accredited AYUSH hospitals. Most modern group plans include AYUSH cover up to the full sum insured.

What's Often Added as Riders

• OPD (Out-Patient Department) cover. Doctor consultations, diagnostic tests, and medicines without hospitalisation. Typically capped at ₹5,000 to ₹25,000 per family per year.
• Dental cover. Routine cleaning, fillings, extractions, and dental procedures. Usually a sub-limit of ₹5,000 to ₹15,000.
• Vision cover. Eye check-ups, prescription glasses, contact lenses. Typically ₹2,000 to ₹10,000 sub-limit.
• Mental health cover. Therapy sessions and psychiatric consultations. IRDAI mandates parity for mental health; many group plans include 10 to 25 sessions per year.
• Critical illness rider. Lump-sum payout on diagnosis of listed critical illnesses such as cancer, stroke, or heart attack.
• Top-up cover. Additional sum insured beyond the base policy, with a deductible.
• Wellness benefits. Annual health check-ups, gym memberships, teleconsultation.

What's Typically Excluded

• Cosmetic surgery (unless medically necessary)
• Self-inflicted injuries and substance abuse-related treatment
• Treatment outside India (unless international cover is specifically included)
• War, terrorism, nuclear contamination
• Fertility treatments (typically a separate rider)
• Experimental or unproven treatments
• Routine eye and dental check-ups (unless OPD rider is included)

What Defines Coverage Quality

• Sum insured per family — ₹2 lakh to ₹10 lakh is the typical range; higher tiers go up to ₹50 lakh
• Room rent structure — capped percentage, single private room, or uncapped
• Co-payment — percentage borne by employee, particularly for dependants
• Sub-limits — caps on specific procedures regardless of total sum insured
• Network depth — number and geographic spread of cashless hospitals

How Plum Structures Coverage

Plum group health insurance is available for Indian companies starting at 7 employees, with pre-existing conditions covered from Day 1 and the IRDAI-mandated 1-hour cashless pre-authorisation. Plans can include maternity, OPD, dental, mental health, and wellness riders based on employer preference. Plum partners with multiple IRDAI-licensed insurers, so the cashless hospital network depends on the insurer chosen for the plan. Plum's median pre-authorisation TAT is 45 minutes, and claims NPS is 79.

Frequently Asked Questions

Is OPD covered under group health insurance?

OPD is not part of standard group plans but is widely available as a rider, typically capped at ₹5,000 to ₹25,000 per family per year.

Are pre-existing diseases covered from Day 1?

Yes, in most group health insurance policies. This is a key difference from retail policies, which apply up to 36 months waiting period under IRDAI 2024 rules.

Does group health insurance cover dental and vision?

Standard plans usually don't include routine dental and vision. Both are commonly available as optional riders with sub-limits.