Group Health insurance (GHI) policies are taken by the corporates covering employees and their families including dependent spouse, children, parents / parent in law. GHI policies can be tailormade as per the requirement of the corporates. These policies can be tailormade in such manner that all sort of pre-existing diseases and / maternity cover can be covered from day one which usually can’t be available in any or normal retain health policy (without any waiting period) taken individually by a person for self or his family from any insurance company.

Below are the coverages in GHI policy:

  • Room Rent : 1% of sum insured for normal room and 2% of sum insured for ICU. This capping can be enhanced or totally removed as per required of the corporate.
  • Pre-Existing Diseases (PED) : Can be covered from day one as the case may be as per the requirement of corporate.
  • Maternity cover: Though it is not covered but the same can be covered from day one as per the requirement of corporate.
  • 30 Days waiting period: Usually there is waiting period of 30 days but the condition can be removed as per the requirement of corporate. If PED is taken from day one, the clause of 30 days waiting period is also removed for the corporate.
  • Co Payment: Such policies can be issued with absolute no co-payment as per the requirement of corporate.
  • Cashless claim settlement across PAN India at network hospitals.
  • Pre & Post Hospitalization expenses: GHI policy provides provision to claim reimbursement of 30 days of pre hospitalization expenses & 60 days of post hospitalization expenses.
  • Disease wise sub-limits : Policies can be issued with some disease with sub-limits or with no sub-limits which is totally as per the requirement of corporate.
  • AYUSHTreatment: Policies has the provision to cover for AYUSH treatment but the same will be available within some sub limits as per guidelines of insurance company.
  • Ambulance Charges: Policies cover ambulance charges of INR 1000 – 2000 per instance as per the requirement the requirement of corporate.
  • OPD Treatment: limit for OPD treatment can be given subject to payment of additional premium by corporate as per its requirement.
  • Corporate Floater: There is provision to have additional sum insured over base sum insured of family in a GHI policy. Such corporate floater can be given as per the requirement of corporate on payment of additional premium. The conditions to use corporate floater in GHI claim is that – (a) the insured person should be inpatient care, (b) His base sum insured of family floater is exhausted in treatment of a disease & (c) such disease is a critical illness or a medical treatment require solely or directly due to an accident.
  • Choice of TPA in claim settlement.


  • War & Nuclear Perils
  • Infertility & related ailments
  • Diagnostic or laboratory expenses not consistent withtreatment
  • Admin / Registration / Service Charges

A major development in the field of Group Health Insurance is the introduction of the third party administrator (TPA). Several insurers across the world utilize the services of independent organizations for managing health insurance claims. These agencies are known as the TPAs.

In India, a TPA is engaged by an insurer for provision of health services which includes among other things:

  • i. Providing an identity card to the policyholder which is proof of his insurance policy and can be used for admission into a hospital
  • ii. Providing a cashless service at network hospitals
  • iii. Processing of claims

TPAs are independent entities who are appointed by insurers for processing and finalizing health claims. TPAs service health policyholders starting from issuance of unique identity cards for hospital admissions up to settlement of claims either on cashless basis or reimbursement basis