GIPSA, PPN and Empanelment in Health Insurance - Explained
GIPSA, PPN in GIPSA, Points to remember before opting GIPSA services, hospitals, empanelment
February 20, 2023
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Before we go on to understand the waiting period in group health insurance, let’s look at health insurance.
The waiting period refers to the time between buying and exercising a health insurance policy. Or simply put, it is the duration of time one needs to ‘wait’ to start filing claims using their insurance policy. That is, the policyholder won’t be able to claim till the waiting period is over.
Sometimes, people would want to buy their insurance policy when they get to know they have huge health-related expenses coming up. Now, this is a huge loss to the insurers if they settle the expenses when claimed. To avoid this risk for the insurer, there exists a waiting period. During the waiting period, the insurer keeps collecting premiums but won’t settle claims.
Waiting periods tend to vary from insurer to insurer. They can be differentiated into some general categories -
It is the waiting period in the starting stage of your health insurance policy. The initial waiting period, also known as the cooling period, starts from day 1 of you buying the insurance. The most common initial waiting period is between 30-60 days but it can vary with different insurers. An initial waiting period is a common waiting period given to all insurance policy buyers.
The maternity insurance generally covers delivery, delivery-related hospitalization and newborn (up to 90 days after birth). When you buy health insurance with maternity, there’s a waiting period of up to 2 years. Again, the waiting period depends on your insurer. If you or your spouse deliver a baby within the waiting period, it won’t be covered.
Before providing health insurance, your insurer will ask you to go through some medical tests to disclose any current injury, ailment, or medical condition. If you have any disease or medical condition, it will be labelled as a pre-existing disease.
As per the IRDAI (Insurance Regulatory and Development Authority of India) norms, any disease, ailment, injury or condition, diagnosed up to 48 months prior to issuing health insurance, comes under the umbrella term, pre-existing diseases.
Some chronic illnesses, for instance, thyroid, blood pressure, and diabetes are all examples of the same. An insurance provider will have a specified duration of the waiting period in such cases. On average, it can be 2 to 4 years.
For instance, Priya will be needed to provide her complete medical records to her insurer before buying a policy. Now let’s assume that Priya has diabetes and there’s a 3-year waiting period for that disease with her insurer. In this scenario, Priya will only be able to claim her expenses related to diabetes after the waiting period is over. Otherwise, her claim will get rejected by her insurance company. However, she can claim expenses for other treatments that she takes which don’t have a waiting period.
There are some diseases that are pre-decided to have a waiting period irrespective of the chosen policy. A few of these include hernia, cataract, endometriosis, some neurodegenerative disorders, fissures, tumors, etc. The waiting period may vary from 1 to 4 years, depending on your insurer.
In health insurance, treatment for mental health has been welcomed and incorporated. In health insurance policies, a waiting period of 24 months is often given to claim the costs incurred in psychiatric illness cases. The IRDAI has also mandated that no insurance provider can reject policies for those who have taken antidepressants before the issuance of their policy.
As accidents are “accidental” in nature few insurers put zero waiting periods and some accept claims after the initial waiting period as specified by your insurer.
Group health insurance (GHI) has zero waiting period. A company provides group health insurance to its employees. GHI has zero waiting period because the risk is spread among all the employees. From an insurer's point, one person buying insurance and getting hospitalized is more likely than a company buying insurance for 150 employees and 5 people getting hospitalized. This is in fact one the major attraction for employers and HRs when they buy group medical insurance. They want to offer the best experience and the most value with group health insurance.
This means, that if you have group medical insurance provided by your organization, you can claim for your treatment from day 1.
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