Corporate Health Insurance, Possible Hazards and Checklist

Corporate health insurance is a valuable benefit offered by companies, organizations, and institutions to their employees. Over the last few years I have personally navigated the complexities of corporate health insurance and also spoke with others about their experiences, I've gained insights into common hazards, pitfalls and areas for improvement.

Even if your current corporate health insurance seems to be running smoothly, I urge employers, employees, and senior staff to review the following points. Addressing these proactively can significantly enhance the value and effectiveness of your plan, ensuring a better experience for everyone.

Here are the key areas I recommend you examine if you currently provide or are considering providing corporate health insurance to your employees:

Ownership and Transfer of Ownership

One often-overlooked aspect of corporate health insurance is who actually owns the policy. In many corporate setups, the organisation (the office), not the individual employee, is the insurance policy owner. You might find the company's name and address on your insurance documents as the primary contact.

This ownership typically doesn't cause issues while you're employed. However, problems might arise when you leave your job. When you leave your job, transferring that ownership to you as an individual or to your new employer can become incredibly complicated, often due to a lack of established procedures. I've personally witnessed situations where transferring ownership was impossible because no such process existed. This often requires written confirmation from the HR head, and without a predefined process, it can become a significant hurdle. I have personally lost my own health insurance because even after a lot of attempt from my side, no one helped to transfer the insurance, neither the office, nor the insurance company.

Admins and Finance Persons are not the Best Insurance Managers

While office administrators and finance managers are often efficient in general administration or audit work, they may not be the best people to handle all insurance-related tasks within your office. One must have specific expertise and experience of managing insurance processes, such as claim submissions and responding to post-claim queries

A person without sufficient prior experience in dealing with insurance processes might inadvertently cause major errors and delays. This may lead to frustration for employees trying to access their benefits. It's crucial to ensure that the individuals responsible for insurance matters have a deep understanding of the intricacies involved.

By entrusting insurance management to someone with experience of handling claims and navigating insurer communication, a smoother, more effective experience for your employees can be ensured.

Pre-Existing Diseases Declaration

This is absolutely crucial to declare all pre-existing medical conditions for yourself and anyone else covered under the policy.

Failing to properly disclose these conditions during the application process can lead to significant problems, especially when you make a claim during hospitalisation. Insurers can deny coverage for undisclosed conditions, leaving you responsible for hefty medical bills. 

At your office, they may declare "no pre–existing disease" even without asking you. This might come back as a boomerang. Please be vigilant.

Your corporate insurance might turn into a nightmare.
Employers and employees need to be vigilant.

Co-pay, Waiting Period, Terms and Conditions

It's possible your office administrator, perhaps due to inexperience, simply collected your basic documents like a passport-size photo and ID, processed your corporate insurance. They did many insurance policy inception in the similar way and considered it an achievement. 

I strongly suggest you to thoroughly review your insurance application form and the entire policy document. Don't just skim it; dig into the specifics. Here are a few critical elements you should pay close attention to:

Co-pay Clauses

Check for any co-pay or expense-sharing clauses. This is a common feature where you're responsible for a percentage of the total bill, even after the insurer approves the claim. For instance, policies, especially for individuals over 60, often include a 30% co-pay. This means if your hospital bill is, say, ₹100,000, the insurance company might only cover up to ₹70,000 (before other deductions). Understanding this clause is vital for anticipating your out-of-pocket expenses.

Waiting Periods

Don't assume your coverage begins immediately for all conditions. Most insurance policies have waiting periods for certain diseases and procedures. This means you won't be reimbursed for claims related to these conditions until a specific time frame has passed since your policy began.

1. For many critical diseases, there's typically a 2-year waiting period.
2. Procedures like knee-replacement surgery often have a 3 to 4-year waiting period.
3. Psychiatric treatment can have a waiting period of 4 to 5 years.

Until you fully understand these waiting periods, please don't consider yourself financially secure for hospitalisation due to these specific conditions. Your insurance document or website will contain a complete list of waiting periods for various diseases.

Ineffectiveness of Small Sum Assured

While a corporate health insurance policy of ₹200,000 or ₹300,000 might seem like a decent benefit, it can be surprisingly ineffective when faced with actual medical expenses. Let's break down why.

The Impact of Capped Room Charges

Most insurance policies have a clause that limits the maximum daily room charge to 1% of the total sum assured. So, if your total coverage is ₹300,000, the maximum you can claim for your daily hospital bed is ₹3,000.

Consider this: In a metropolitan or cosmopolitan city, general hospital bed charges often start from ₹3,000 or ₹4,000 per day. An Intensive Care Unit (ICU) can easily cost between ₹6,000 and ₹12,000 or more daily. If you're admitted to an ICU with a daily bed bill of ₹8,000, and your policy only covers ₹3,000, you'll be paying ₹5,000 out of your own pocket every single day, just for the bed.

The Proportionate Deduction Clause

Here's an even more significant catch: The bed charge is often considered the "central expense." This means that all other hospital expenses will be deducted in the same proportion as your bed charge limitation. For example, if your policy only covers 37.5% of the actual bed cost (₹3,000 out of ₹8,000), then only 37.5% of your doctor's fees, medicine costs, and other charges will be covered, even if those specific expenses are within your overall sum assured. This "proportionate deduction" clause can make your final hospital bill shockingly high, even for a seemingly modest amount.

In essence, a ₹200,000 or ₹300,000 insurance policy in today's healthcare landscape covers only a small fraction of typical hospitalization expenses.

Equality vs. Utility in Policy Allocation

Often, companies choose to provide a ₹200,000 sum assured to ten staff members instead of a ₹1,000,000 policy to two. While this approach might be intended to maintain equality among employees, in practical terms, these lower sum assured policies offer very little real utility when a significant medical event occurs.

Insurance Usage Audit

For employers, I strongly recommend conducting a regular insurance usage audit. Since your organisation is typically the insurance owner, you have direct access to valuable data from your insurance provider. Analyzing this data can provide critical insights into the effectiveness and value of your corporate health insurance plan.

Here are key metrics you should review:

1. Claim Volume: How many claims were filed within a financial year?
2. Claim Success Rate: What percentage of submitted claims were successfully processed and reimbursed? This indicates how smoothly the claims process works for your employees.
3. Post-Employment Continuity: For employees who left your organization, how many continued their insurance policy for at least one premium payment? This sheds light on the perceived value of the policy.

You don't need to invade individual privacy to do this. Focusing on aggregated, larger datasets will provide the necessary insights to understand if your corporate insurance is truly serving its purpose and benefiting your employees effectively. This data-driven approach helps you optimise your employee benefits and ensure they deliver real value.

Just as social and welfare schemes track only the funds disbursed without often studying the actual outcomes, many companies make a similar oversight with employee benefits like insurance. It's not enough to simply offer a policy; you must also study its actual usage and results.

Institutions with Limited Budget or FCRA Organisations with Admin Expense Limitation

Institutions operating with limited budgets, or FCRA (Foreign Contribution (Regulation) Act) organizations facing administrative expense limitations, often find providing comprehensive health insurance a challenge. Here are some suggestions to optimize your employee health insurance program when funds are tight:

Eliminate Duplicate Coverage

It's common for employees and their families to have existing health insurance coverage from other sources, such as through a spouse's government or corporate employment. When budget is a concern, eliminating duplicate insurance can free up significant funds.

Ideally, your initial insurance list shouldn't include individuals who are already adequately covered. However, in practice, I've observed that even those with existing coverage often choose to take the corporate insurance as well. Review your organization's current policy and practice regarding duplicate coverage to see how you can best manage this.

Lower-Paid Staff are Insured First

I strongly advocate for a policy where the lowest-paid staff members are insured first. This means office support staff, junior associates, and other less compensated employees would be prioritized for coverage, with higher-paid staff like Executive Directors and Chief Officers being added later or if budget allows. This approach ensures that those who might face the most significant financial hardship due to medical emergencies are protected first.

Implement an "Opt-Out" Option

Provide an "opt-out" option for employees. If a staff member believes they don't need the corporate health insurance because they're already well-covered or can take care of their hospital bills, they should have the choice to decline the benefit. This not only respects individual choice but also allows you to reallocate funds to cover other employees or enhance existing benefits for those who genuinely need it.

This article has been written in Indian context. You may share your experiences in the comment section below. Please do not include any specific company/organisation or any individual's name. I'll answer your queries, if I can. However, I won't be able to solve your TPA (Third Party Arrangement, i. e. Insurance).

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This page was last updated on: 29 June 2025
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