Have you ever sought details of the Employer Health Insurance policy availed to you by your employer? Who in your family is covered under this plan? Are your parents, spouse and children adequately covered? Did you discuss the insurance coverage or read about the company’s terms and conditions before assenting to the same? If not, it’s time to understand what the group health insurance plan offered by your employer is and if the same is in sync with what you need.
How long do you have to wait?
To start with, check the benefits offered by the employer’s health insurance plan. Are there any unique benefits like the availability of coverage for pre-existing diseases for yourself or your parents immediately after joining or do you have to wait for a specified period before claiming money for treatment at a hospital? Most health insurance plans are effective from the date of joining and ensure coverage throughout the employment tenure.
Sumit Ramani, Actuary & Co-founder, ProtectMeWell.com, “In a group insurance policy, the anti-selection risk is reduced significantly because, by definition, the group didn't come together with the primary purpose of buying insurance. They decided to work for an organization and the organization happens to cover them against health risks. Additionally, everyone in the group is generally enrolled in insurance coverage further ensuring that both healthy and not-so-healthy populations join the pool. Given the foregoing, group mediclaim policies are more relaxed in terms of medical underwriting and waiting periods, but pre-existing disease waiting periods do apply for group insurance covers. The waiting period is typically shorter and, in some cases, waived at an additional cost and/or post-medical underwriting, implying that claims can be made as soon as the policy is purchased.”
While this may be deemed as an essential benefit, this may not be of much use considering how not too many employees may make policy claims immediately after joining the organization. Furthermore, employees are not automatically enrolled in insurance plans after being hired. There are myriad processes involved like submitting names and other details of family members apart from filling out some forms, etc.
If you want your entire family to be covered by your employer's health insurance plan, you must not rely on the HR department to fill out your information. Fill out the form yourself instead, as incomplete or incorrect information may result in claim rejection.
It makes sense to find out if the insurance company mandates a waiting period before you can make any claim on the policy.
Who else is covered besides me?
All employers may be generous, which means that they may be willing to cover only their employees while leaving their dependents in a lurch, in case needed. Also, many employers negotiate on premium charges too, which means that a part of the premium amount may be deducted from your salary. Ask your HR about the premium charges and if you must pay extra for family coverage.
Viral Bhatt, Founder, Money Mantra says, “First, check the cost of adding your family members. For this, you will need to evaluate the additional premiums required to add your family members to your employer's health insurance plan. If the cost is reasonable and fits within your budget, it may make sense to add them. Second, do not ignore your family’s healthcare needs. Consider the health care needs of your family members. If they require frequent medical attention, adding them to your employer's health insurance plan can help you save on healthcare expenses in the long run. Third, check for the coverage and benefits offered. Review the coverage and benefits offered by your employer's health insurance plan to determine if it meets the needs of your family members.”
Numbers matter and a penny paid extra may be a penny spent unwarrantedly. Do some preliminary math to determine if adding someone to your plans is the best financial decision for you.
Did you get your TPA card?
Have you asked the company for the Third Party Administrator (TPA) card? Are you aware that you cannot seek cashless hospitalization and treatment unless you show your TPA card issued by the employer’s health insurance? If the company does not issue a physical card, you can ask for an e-card with a valid ID. So, until you get the TPA cards for everyone in your family, ask your employer’s HR for the card. Once you receive your card, please check that all information on the card is correct including name, age, contact information and insurance coverage for a seamless policy claim.
Check the list of hospitals in network
You cannot simply walk into a hospital and expect to be treated for your problem with the available insurance coverage offered by your employer. Insurance companies have relationships with a specific list of hospitals called networked hospitals, which is why you must check if your choice of hospital is included in the list. This is because if you receive treatment at one of these hospitals, you will either receive non-cash benefits or be reimbursed for the amount spent on the treatment. So, make a list of these connected hospitals in advance and keep them handy. This way, in the event of an unexpected hospitalization, you can go directly to the list and quickly access the closest one.
Does the health plan offer special coverage?
You may not be comfortable disclosing your medical history before being hired, but if you have a medical condition, you may need extra assurance that your health insurance will meet your needs. To put all unwanted worries to rest, why not request a copy of the benefit illustration (BI) to understand the diseases covered and the extent of coverage available along with applicable conditions? For the unversed, the 5-10 paged BI includes details of what prospective or new policyholders must know about how insurance works under the specific conditions described in the book.
Suresh Sadagopan, MD & Principal Officer, Ladder7 Wealth Planners shares, “It will be mentioned in the group insurance policy wording. If it is not clear one can approach their HR department who can give that clarity.”
It’s okay that you have bought your own health insurance plan. That should not cause you to refrain from benefiting from your employer-sponsored health insurance policy though there are certain limitations considering how you cannot customize the latter or seek changes in the policy or ask for greater coverage as per your need. Corporate health insurance must be looked at as an added benefit; ensure that you do not rely on it completely to pay for your hospitalization and subsequent treatment.