Group Health Plans Must Cover some COVID-19 Testing

A group of people belonging to different age brackets coming together with a similar interest of receiving health coverage at a lower premium cost and subsequently subscribe to a health plan thus, the policy is called group health insurance. 

A group health insurance plan is cheaper than personal healthcare policies. The Insurance Regulatory and Development Authority of India (IRDAI) states that a group formation can be possible on the grounds of people having the same credit card, common bank as well as members belonging to a social group. 

How does Group Insurance work?

Group insurance is also provided to employees by their employers belonging to an organization. As large corporations are the main players in this policy, the plan is also known as corporate health insurance or employee health care. These plans are employer-sponsored in most companies although, some organizations can put forward the clause of co-payment. Co-payment or co-pay means that the employee in collaboration with the employer will be contributing towards the payment of the insurance premium. A pre-decided ratio of the payment has been set.

Features of group health insurance: 

• Pre-existing diseases – 

Under group health insurance, the insured asks the members if they are suffering from any medical condition as they need to disclose the same according to the non-disclosure clause. In some cases, the insured needs to serve a minimal waiting period, whereas, on the other hand, the pre-existing conditions of the insured are covered since day one. 

• Hospitalization – 

The insured has to undergo some medical issues and needs immediate professional care then the person needs to be given admission to a hospital. Once the insured is admitted to a hospital, the insurance company will look after all the costs associated with the same. The policyholder is admitted to one of the network hospitals and can enjoy the benefit of cashless coverage or else the reimbursement mode kicks in. 

• Pre- and post-hospitalization – 

Pre-hospitalization costs include expenses, such as blood tests, lab reports, blood pressure checks, and so on as such sensitive information helps the doctors who will be treating the patient to handle the case cautiously thus not causing any further complications. Post-hospitalization expenses consist of expenses such as routine doctor appointments, medications, and more. 

• Dependents – 

The employer gives the employees an option of extending the insurance policy to their immediate family members like spouse, children etc. Although the premium for the family members has to be paid by the employee that means the amount payable will be directly deducted from the worker’s pay. 

• Premium – 

The premium for a group insurance policy is usually paid by the employer, although in some cases the employer asks the employees to co-pay. Co-payment means that out of the entire premium payable, the employee shall contribute a minor amount. The ratio of the payment is pre-decided, and once the worker agrees, the policy is in motion.

• Ownership – 

It is an assumption that the person providing or offering such a proposal, the name of the plan will be in the employer’s name. although as the policy covers employees of a certain organization, the name of the policy that is the owner will be on behalf of the company. The company’s name will be the name of the policy.

• Medical check-up – 

As pre-existing diseases are covered by the insurance company from day-1. All the members need to do is inform the insured about any medical condition they are suffering from and thereby not violate the non-disclosure agreement. This helps the insured have information about all the sickness and thus, cover the expenses or treatment costs related to the same. Hence, no medical check-up needs to be undertaken.

• Ambulance charges – 

In cases of emergency, the insurance company covers ambulance charges too up to a certain limit. There is a possibility that some health care providers do not provide the same, and thus it will be wise for one to go through the terms and conditions of the policy and/or ask the company’s clauses. 

• Waiting period – 

The insurance companies do not ask the members of the group to serve a waiting period in most cases as one of the positive sides of having a group insurance policy is that the waiting period under the plan is easily waivable. This means that it depends on the type of situation the insurer is looking at and thereby decides whether the participant needs to serve a waiting period or not. 

Group health insurance and Covid-19: 

Many health providers ask the general public to undergo a Coronavirus test only if they have come in contact with a COVID-19 positive result or have been traveling abroad as well as if they are facing severe symptoms. Taking up a COVID-19 test just for the sole purpose that it is easily accessible is not a valid reason. The IRDAI has re-directed to the insurance holders that having an existing health care policy is good enough for covering Coronavirus costs, and one doesn’t need to purchase a special COVID-19 coverage plan. 

An insurance company, may it be a personal health or group health care, the insurer will provide COVID-19 test costs to the insured on grounds that the policyholder gets admitted to a hospital for the same. The Coronavirus test will further lead to hospitalization for the insured to file a valid claim. The test costs will be considered as a pre-hospitalization test. One shall also know that the insured needs to get hospitalized within 30 days of testing positive for Coronavirus. The condition of getting professional medical care that is getting hospitalized is based on the principle of a minimum of 24 hours of hospitalization. 

The COVID-19 test will be treated as routine health claims. Insurance providers have stated that if the policyholder gets admitted to a government-approved facility, the claim will be treated as hospitalization expenses and duly reimbursed. If the policyholder tests negative for Coronavirus, the insurance company is not liable for those costs. Hospitalization for a minimum of 24 hours is required for one to file a valid claim.

Group insurance will not be providing any claims for home-quarantine treatment which means that if the insured tests positive for Coronavirus but due to the condition being powerless, hospitalization is not required, and thus the COVID-19 positive person is home quarantined with the necessary medications. If the insured has OPD (out-patient department) benefit then the policyholder can claim costs of the Coronavirus test along with the medication expenses from the insurance company. 

• Employers and COVID-19 test: 

Employers provide health care benefits to the employees by offering them group health insurance plans to safeguard their well-being from various hazardous illnesses and diseases. In the era of COVID-19, the choice of employers has slightly tilted from profits of the organization towards employees of the organization for the sole purpose that the workers will be the stepping stone to the company’s profits. 

It has become a necessity that the employee needs to undergo a Coronavirus test, and the result needs to be negative for the worker to return to the workplace. If the conclusion of the test is positive, the employee needs to either home quarantine or can get admitted into a hospital. As we are already acquainted with the fact that for claiming COVID-19 test costs, the employee needs to get hospitalized for a minimum of 24 hours, and if the result is negative it does not result in a constructive claim. 

Many employees have raised the claim that the test costs shall not be borne by them as the test is a requirement for the organizations and thus the expense shall be wholly or partly be made by the company. Many of the IT companies like Infosys and TCS have not only agreed to sponsor the cost of Coronavirus tests for their employees but also the cost of the vaccine for their employees.

Many such claims have been filed by employees working in foreign countries. According to the Americans with Disabilities Act (ADA) guidelines, employers are obligated to pay the COVID-19 test costs in certain circumstances. The regulation clearly states that if the employer feels that the employees not undergoing COVID-19 tests cause a “direct threat” to the organization, and so if the employer asks the employee to undergo such a test then the work provider must pay all the associated costs of the test. 

Many employers are not voluntarily paying these costs as they do not want any such issue to cause a direct impact on the company’s morale.