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What is not covered in group health insurance?

Group health insurance has a list of certain exclusions which are not covered under the policy and are considered as permanent exclusions under the policy that are mentioned below: -

  • Any kind of medical expenses incurred due to treatment related to rehabilitation from addictive conditions or disorders or from any kind of substance abuse or misuse is not covered under the group health insurance policy

  • Treatment related to relieving the aging or puberty or other natural psychological cause is not covered under the group health insurance policy. 

  • Expenses incurred for circumcision unless necessary for treatment of a disease or necessitated by an accident are not covered. 

  • Expenses incurred solely for convalescence, rehabilitation, supervision or any other purpose other than for receiving eligible treatment is not covered under the group health insurance. 

  • Expenses incurred for cosmetic surgery or beauty improvement operations are not covered under the group health insurance policy. 

  • Treatment for external congenital anomaly is not covered. 

  • Medical expenses incurred for treatment towards unproven or experimental treatment is not covered. 

  • Any expenses incurred above the maximum liability of the insurance company under the group health insurance policy. 

Group health insurance covers the medical expenses incurred for hospitalization such as in-patient, outpatient, day care etc. The other expenses such as organ donor expenses, ambulance charges, convalescence benefits etc would be paid as per the limits mentioned under the policy. Group health insurance also includes the buffer cover where the sum insured can be utilized by any of the members at the discretion of the employer. The terms and conditions for the utilization of the corporate buffer would be same as that of the basic sum insured and the deviations can be availed on this on a case to case basis. 

Corporate buffer is the extra sum insured that is available under the group health insurance plans which can be distributed to any of the members under the plan after the exhaustion of the basic sum insured during the policy period. It is important to note that neither the corporate buffer sum insured cannot be carried forward to the next policy period at the time of renewal nor there would be premium refund for the unutilized sum insured under the corporate buffer section. 

The corporate buffer sum insured also has the same exclusions which are mentioned above and the sum insured cannot be utilized for the above mentioned conditions. Most of the group health insurance policies can be availed with waiting periods to reduce the premium. In such cases the medical expenses incurred before the waiting period would fall under the exclusions under the policy. There are certain waiting period exclusions such as pre-existing disease, specific disease, initial waiting period, maternity waiting period etc. There would be no waiting period for the hospitalization expenses incurred as a result of the accident. There are sub limits for certain illnesses under the group health insurance policy under which the sum insured for certain illnesses would be a certain limit of the basic sum insured. 

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