How to read your group health insurance policy?

What should you check in a group health insurance policy?

When it comes to employee benefits, group health insurance is one of the most appreciated perks in any company. It provides financial protection to employees and their families in case of medical emergencies. However, many HR leaders and decision-makers often make the mistake of just skimming through the long, 20–30 page policy document. They may look only at the total premium cost or read the insurer’s summary, thinking that’s enough.

The problem with this approach is that it can create confusion or misunderstandings later. Employees may face rejected claims or unexpected expenses because important details like coverage limits, exclusions, or waiting periods were overlooked.

Start with the policy schedule

The policy schedule is like a quick snapshot of your group health insurance plan. It tells you the key details at a glance. Always check this first:

• Policy number & validity – Make sure the start and end dates match your company’s needs. There should be no gap in coverage between renewals.
• Total members covered – Count the number of employees and their dependents covered. If this doesn’t match, claims might get rejected.
• Premium – Check the total premium, GST, and any extra charges.
• TPA & broker information – Know who handles claims (TPA) and who your broker is. These are your main contacts for help when employees need to make a claim.

Verify coverage details in group health insurance plan

It’s important to understand who is covered and how much coverage they have under the policy. Check the following carefully:

• Sum insured – Find out if the coverage is a floater (shared by the entire family) or individual (separate cover for each member). This shows how much each person can claim.
• Family definition – Confirm which family members are included. Does the policy cover spouse, children, parents, or in-laws? 
• Age limits – Most policies have maximum ages for adding dependents or employees. Check that these limits make sense for your workforce.

What group health insurance benefits should HR check?

You should carefully check the following:

• Hospitalization coverage – Look at what the policy covers when an employee is admitted to the hospital. Check room rent limits, ICU charges, and surgery costs. Some policies cap certain charges, so it’s important to know the limits to avoid surprises.
  
• Maternity & newborn benefits – If your employees are planning a family, check the coverage for maternity. This includes limits for normal or C-section deliveries. Also, see if the newborn is covered from day one.
  
• Pre & post hospitalization – Some medical expenses before and after hospitalization are also covered. Check how many days before admission and after discharge the policy will pay for treatment, tests, or medications.
  
• Ambulance charges – Confirm if ambulance services are covered per hospital visit or per year. Many policies have a cap, so employees may need to pay extra if the limit is exceeded.
  
• AYUSH treatments – Many employees prefer alternative medicine like Ayurveda, Yoga, Unani, Siddha, or Homeopathy (AYUSH). Check if these treatments are included and what the limits are.
  
• Preventive & wellness benefits – Some policies offer extra value like annual health check-ups, mental health support, and wellness programs. These benefits can help employees stay healthy and reduce long-term medical costs.

What are sub-limits and co-pay clauses HR should check?

Even if a group health insurance policy provides coverage, some limits can lead to unexpected expenses. HR should check:

• Is there a room rent cap? Lower room limits can mean employees pay more out-of-pocket if they choose a higher-category room.
  
• Are there disease-specific limits? Certain treatments like cataract surgery, maternity, or any surgery may have a cap.
  
• What about ambulance and other sub-limits? Some charges may be covered only partially or up to a set limit, which might be less than actual costs.
  
• Is there a co-pay? Check if employees need to share a percentage of costs, especially for older employees or parents covered under the policy.

What extra clauses and limits should HR know about?

Sometimes, small clauses in a group health insurance policy can have a big impact. As an HR professional, you should check:

• Corporate buffer – Some policies provide an extra pool of money for unusually high claims. This can prevent claim rejections when multiple employees need expensive treatments. Check if your policy has it.
• Portability – Can employees move their coverage to an individual plan if they leave the company?
• Exclusions – Cosmetic, infertility, obesity surgeries, self-harm or any other.
• Claims process – Know cashless vs reimbursement, timelines, TPA/broker contacts, and escalation path.

Conclusion

By reading beyond premiums and carefully checking benefits, exclusions, and processes, HR can ensure that employees feel protected when they need it most. Treat the policy document as a playbook for employee wellbeing.

Take the next step: Simplify your group health insurance and empower your employees with Pazcare.