Employee Health Insurance policies are insurance policies extended by your employer to protect you and your family in the event of a medical emergency. The employer will bear the cost of insuring you, as an individual, and sometimes may also bear the costs of insuring your family — including your spouse, children or your parents. And while employee insurance policies may not offer the most comprehensive protection, there are some obvious benefits tied to these policies nonetheless.

Benefits of Employee Health Insurance Policies

  1. These policies are often priced cheaper compared to similar policies available on the retail market — This anomaly boils down to two factors.
    a) Risk is often spread across a larger group of employees.
    b) And premiums are often negotiated without middlemen.

  2. The policies don’t entail waiting periods. Most retail policies (policies that you can buy directly from the insurer) will make you wait a few years before covering certain diseases. For instance, they may impose a specific disease waiting period — a 2 year cool off period during which they may not cover complications arising out of cataracts, gastrointestinal problems, cancer and other such illnesses. In some cases, they may also impose a pre-existing disease waiting period — during which time pre-existing diseases including Diabetes and Hypertension will be excluded. Employee insurance policies meanwhile don’t impose such restrictions.

  3. Employee insurance policies may sometimes be your only recourse for protection. Considering retail policies often have strict entry conditions, you may not be able to get your hands on a policy if you were previously diagnosed with cancer or other critical illnesses. Employee insurance policies on the other hand are usually available to all employees irrespective of their past medical history.

  4. They also often cover maternity-related expenses and other expenses you may incur while tending to complications associated with your newborn
    If you have parents that need protection, it may be really to find a retail policy that fits their needs. Employee insurance policies on the other hand may extend protection to your parents despite their old age.

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Downsides of Employee Insurance Policies

  1. The coverage may be insufficient: Most employee insurance policies offer coverage of only up to 5 lakhs. This kind of protection may be insufficient especially considering you may have your parents included in the plan as well
  2. Less comprehensive: Some employers tie up with insurance companies to create a sub-par product that costs less. This is usually due to the fact their incentives aren’t always lined up with those of their employees. So it always makes to read your policy document one more time in a bid to confirm what’s covered and what’s not.
  3. You are always at the mercy of your employer: Your employee insurance plan will be active so long as you are employed. But once you quit, you’ll be booted out of the group plan. The insurance company however may offer you the provision to port to a similar retail plan off the shelf, but this will also be incumbent on many factors - including any pre-existing conditions.
  4. It can be very expensive: Although there’s very little you can do about this aspect (since the employer puts up the premium after accounting for it within the CTC), it can be prohibitive on some occasions.

Should you buy a separate insurance policy if you have an employee insurance plan?

It depends. Employee insurance policies can come in extremely handy on some occasions and retail policies can offer you protection on other occasions. It is ultimately incumbent on your use case.

So let’s see when it makes sense to prioritize one option over the other.

1. When you have a basic employee health plan with a measly cover


This one is a no brainer. If your employee health insurance policy barely does the basics right, then you definitely need a more robust personal plan. We’ve often seen people end up at the hospital only to find out that the employer offers insurance coverage of up to 2 lakhs. And while that may seem like a decent figure to some people, it’s woefully inadequate for a whole host of use cases. So you may want to consider buying a separate health plan for added protection.

2. When you have an employee health plan with a robust cover but multiple restrictions


Once again, the cover value rarely matters if the health plan offers mindless restrictions. Oftentimes, the employee health plan may impose restrictions on the kind of rooms you can pick, sub limits for specific treatments, and may even exclude daycare treatments altogether. In such cases, it almost always makes sense to buy a separate health plan for yourself.

3. When you have a comprehensive employee plan, and you are not looking to switch jobs

If the employee plan does everything you could possibly think of, and you’re in a stable job without actively thinking about quitting, then maybe you don’t need a personal health plan. Maybe you could buy one later when the status quo does change.

What are the best Employee Health Insurance Policies?

There is no such thing as a best employee health insurance policy since these products are custom contracts drafted specifically for companies based on the specifications they seek. So if your employer lists down comprehensive specifications, you will have a comprehensive insurance plan. Otherwise, you’ll be out of luck.  

How to make a claim if you have an employee health insurance policy?

Most companies will have a dedicated portal to file your insurance claim. If you can’t access it, you should contact your HR or your manager.

You will also need to keep a few documents handy
a) Employee Health Insurance ID Card
b) Any medical records associated with your diagnosis before you’re hospitalized

In the case of emergency hospitalization, you have to intimate your employer (and through them the insurer) as soon as you get the patient admitted. In the event that isn’t possible, you must intimate them within 48 hours of hospitalization.

In the case of a planned treatment, you have to intimate your employer 3 days before admission. But if you can do it sooner, you should probably consider doing that as insurance companies may take a while to investigate the veracity of your request.

Check for partnered hospitals — Each insurer will have a dedicated network of hospitals they’ll have partnered with. Once you find a partner hospital of your liking, you can try to make the claim on a cashless basis. That is to say that the hospital will directly communicate with the insurer and bill them without asking you to pay anything out of pocket

If you try to make a cashless claim, you will have to fill a Pre-Authorization Request Form. Upon receipt of this form, the insurer will validate your claim and approve a sum that will be paid out on a fully cashless basis. In the event the treatment costs exceed this sum, then you’ll have to pay the difference and seek reimbursement once you’re discharged.

The form will be made available to you once you intimate the insurer that you will be making a cashless claim. You’ll have to fill in your personal details and the hospital will fill out the rest. Once complete, you can ask the hospital to submit this form back to the insurer.

If you don’t find a network hospital of your liking or if the cashless claim doesn’t pass, then you may have to file for reimbursement — wherein you pay the full cost of treatment and ask the insurer to reimburse you afterwards

How to file for reimbursement if your cashless claim doesn’t get approved?

  1. Oftentimes insurance companies may be tentative to settle a claim on a cashless basis but will gladly do so once you’ve paid the bill in full. This process is called reimbursement
  2. To file a claim, you will need to visit the employee portal and download the claim form from the insurer's website. Some insurers will also have an online portal for submission.
  3. The claim form is divided into two parts — Part A & Part B. You’ll have to fill out Part A and the hospital personnel will fill out part B. They’ll also have to sign and seal the document
  4. In the meantime, you have to collect and collate all the investigation and medical reports associated with your prognosis
  5. And finally, you will have to mail the original reports to the insurance company (your employer could do it for you as well) and wait for them to process your claim

What documents do you need while making a claim using an employee insurance plan?

1. Investigation and Medical reports: You will need investigation reports signed by your physician and approved by the hospital
2. Discharge Summary: A discharge summary will include further details about your diagnosis, treatments extended and the protocols followed to effectively treat your condition. The discharge summary must be printed on hospital letterhead and include all relevant data, such as the hospital’s address, license number, and contact specifics.
3. The final bill: An itemized bill that includes expenses incurred across the board. It must have specific breakdowns, detailed statements and also include consultation charges
4. Invoice details: Medical implants and other consumables must be supported by the invoice associated with the products

Frequently Asked Questions

  1. Can I switch from an employee plan to an individual policy?
    Yes, you can make the switch from an employee policy to an individual policy once you quit the company. The insurer will assess your application once again and make you a proposal by offering a retail plan that most closely resembles your employee plan.

2.  Do employee health insurance policies let me include my parents?
   Some employee health insurance policies do extend the option of including               your parents. But this will depend on your employer.

3.  Can I avail a discount on employee health insurance policies?
     No, employee health insurance policies don’t offer you discounts.

4.  Do employee health insurance policies offer maternity benefits?
     Yes, most employee health insurance policies do offer maternity benefits.

5. Do employee plans impose waiting periods?
     No, most employee health insurance policies don’t extend waiting periods