Navigating group health insurance can be confusing, whether you're an HR professional managing it or an employee trying to understand your benefits. From deductibles, co-pay, and sum insured to waiting periods, cashless hospitalization, and claim settlement, unfamiliar insurance terms often lead to confusion and even claim rejections. HR teams also spend significant time answering the same health insurance questions and explaining policy coverage to employees.
This comprehensive group health insurance FAQ guide answers the most common FAQs in simple language. Whether you're choosing a group health insurance policy or trying to make the most of your existing coverage, these answers will help you understand your benefits and make informed decisions.
What is the deductible amount?
A deductible is the fixed amount the policyholder must pay before the insurance coverage kicks in.
- For base health insurance: usually ₹0 deductible
- For super top-up plans: deductible can be ₹1–5 lakhs, based on the existing base policy or customer choice
What is the waiting period?
Waiting period is the time span during which you cannot claim some or all benefits of the health insurance from your insurance provider i.e. you must wait for a specified amount of time before you make a claim.
Types of waiting periods:
- Initial wait: 30 days for general hospitalization (except accidents)
- Pre-existing diseases (PED): Usually 24–48 months
- Named ailments (like cataract, hernia): Often 12–24 months
- Accidents: Usually zero wait time
What is pre-existing diseases?
A pre-existing disease is any condition, illness, or injury diagnosed or treated by a doctor within 48 months (4 years) before the health policy starts. Example: diabetes, asthma, hypertension.
What is the initial waiting period?
Expenses related to the treatment of any illness within 30 days from the first policy issuance date are not covered.
What is copay?
Co-pay is the portion of the claim that the policyholder agrees to pay. The insurer covers the rest.
For example, if co-pay is 20% and the bill is ₹1 lakh, you pay ₹20,000, the insurer pays ₹80,000.
What is TAT in insurance?
TAT (Turnaround Time) refers to how long an insurer or TPA takes to respond, process, and resolve:
Each action has a defined TAT as per IRDAI guidelines. You can check it out here
What is sum insured?
The Sum Insured is the maximum amount your insurer will pay in a policy year for medical expenses.
Example: If your policy has a ₹5 lakh sum insured, that’s the upper limit of coverage per year.
What is room rent limit?
Room rent limit is the cap on daily hospital room charges that your policy will cover.
- Some policies have no cap
- Others limit room charges to 2% of the sum insured per day
Choosing a room above this limit may result in proportionate deductions in claim settlement.
What is a network hospital?
Network hospitals are healthcare providers that have a tie-up with your insurer for cashless treatment.
If you visit a non-network hospital, you’ll need to pay upfront and then claim reimbursement.
What is cashless hospitalization?
Under cashless hospitalization, you don’t pay anything at the hospital (except non-covered expenses).
Your insurer/Broker or TPA directly settles the bill with the hospital after pre-authorization.
What is reimbursement claim?
If you take treatment in a non-network hospital, you can apply for a reimbursement claim by submitting original bills, prescriptions, and discharge summary to the insurer.
What is a super top-up plan?
A super top-up plan provides additional coverage once your deductible is crossed.
Example: If your base policy covers ₹3 lakh, and you buy a ₹10 lakh super top-up with a ₹3 lakh deductible, expenses beyond ₹3 lakh will be covered.
What is AYUSH coverage?
AYUSH refers to Ayurveda, Yoga, Unani, Siddha, and Homeopathy treatments. Some health policies cover AYUSH hospitalization expenses as part of the policy.
What is a TPA (Third Party Administrator)?
A TPA is a licensed intermediary between the insurer, hospital, and the policyholder. They handle claim processing, pre-authorization, and grievance redressal.
What is Disease-Specific sub-limit?
Some policies cap expenses for specific treatments like cataracts, dialysis, or knee replacement, regardless of your sum insured.
Example: ₹50,000 sub-limit for cataract surgery even if your total sum insured is ₹5 lakh.
What is the Restoration Benefit?
Restoration benefit refills your sum insured once it is exhausted in a policy year.
Useful if multiple family members fall ill or if multiple claims are raised in one year.
What is Proportionate Deduction?
If you opt for a hospital room with a higher rent than allowed under your policy, insurers may reduce all related claims proportionately, not just the room rent.
What is a Claim Settlement Ratio (CSR)?
The CSR is the percentage of claims an insurer settles out of total claims received.
Always choose insurers with CSR above 90% for reliable support.
What is OPD Cover?
OPD (Outpatient Department) cover allows you to claim for expenses like:
- Doctor consultation fees
- Diagnostic tests
- Pharmacy bills
Usually not included in base plans unless opted as an add-on.
What is Out-of-Pocket Expense?
Expenses you have to pay from your own pocket despite having insurance, includes items not covered like gloves, admin charges, or items beyond room rent limit.
Understanding the ins and outs of group health insurance doesn't have to be complicated. With the right knowledge, you can make smarter decisions for yourself or your team—whether it’s choosing the right coverage, managing claims, or planning for renewals.
Still have questions or looking to design a better insurance experience for your employees?
Get in touch with Pazcare, we simplify group insurance with expert advice, tech-first tools, and end-to-end support.
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