Does Group Health Policy Cover People Who Never Come To The Office?
Yes. Group Health Insurance policy also known as Group Mediclaim policy or corporate health cover, ensures that member's from a defined group generally from one organisation are covered under a single master policy. Eligibility of this policy is based on active employee. In master policy employee are listed as member so, a remote worker is also treated as any other insured member.
Sum Insured doesn't vary with their location, change the waiting periods or restrict hospital which they want to use. This cover is valid PAN India, so if an employee is in any different state they can visit any network hospital for treatment.
What matters is employment type not their work location. Employee those are full-time and are on the payroll are usually covered automatically. Employee those who are not on the payroll like contractors, freelancers, consultants and gig workers are usually not covered under group policy. If the employer wants to specifically include them then it can be consider. Many insurers create a separate category for them.
What Does A Remote Employee Actually Get with a Group Health Policy?
Same benefits which are written in a policy document are given to a remote employee. The structure is standard but the exact figures depends on the plan the employer buys.
Benefit | What it means for a remote employee |
|---|---|
Sum insured | Same amount is given to remote employees regardless of city they live.The maximum the insurer pays per policy year, shared or per member depending on the plan. |
Cashless hospitalisation | You don't have to pay upfront at any network hospital in India for getting a treatment covered. |
Family cover | Dependent like spouse, child, parents or parent-in-law can be added to a group policy. This depends on what kind of policy type you are opting for. |
No waiting period on pre-existing diseases | Initial waiting period on pre-existing diseases are usually waved-off in group health policies. Before buying this policy always confirm this in the employer's policy. |
Maternity cover | Maternity cover is included in group policies but without a waiting period which are usually seen in retail or individual policies. |
Day-care and pre/post-hospitalisation | Treatment which are done under 24 hours are called Day-care procedures and defined pre - and post - hospitalisation expenses which can be on 30/60 days or more are also covered as per policy conditions. |
Group health policies usually price across whole group rather than pricing each individual. That is why group plans often have no or reduced waiting periods, so any remote employee with a pre-existing disease can claim from day one depending on their policy.
How Does Cashless Treatment Work in Group Health Insurance When You're Far From Any Office?
You can apply for cashless treatment even if you are away from your office because it depends on the network hospital of the insurer's or third party administrative and not on the employee's working location. You just have to show your group health E-Cards at the network hospital desk and then rest procedure will be coordinated between hospital and administrative directly.
Steps for Cashless claims are same everywhere in India:
Locate a Network Hospital
To find network hospital, ask your HR, TPA or insurer's for the list or app, website or any kind of portal to search the nearest hospital to their location.
Show The Group Health ID Card
At the hospital desk submit your E-Card or Member ID.
Submit The Pre-Authorisation Request
Your details and estimated expenses are submitted to the TPA for approval before any planned treatment or within 24 hours for an emergency.
Get Approval And Treatment
When TPA approves all documents and covered amount, then hospital treats you without asking any upfront amount for that portion.
Settle The Balance If Any
Items or costs outside the policy terms are paid by you. For eg if the amount is above sum insured or not covered in your policy.
If No Network Hospital Is Nearby
If you are visiting any no network hospital then you can always file for a reimbursement claim after getting your treatment done. You just have to submit all the original documents like original bills, doctors reports, discharge summary and claim form to the TPA. In these kind of cases only your payment method is change, policy terms and condition are same and applicable.
Group Mediclaim - Cashless vs Reimbursement: Which Applies To You?
Both types of claims method are available under same policy structure. This depends on whether the hospital is in the network or not.
Feature | Cashless | Reimbursement |
|---|---|---|
Where it works | Network hospitals only | Any hospital, network or not |
Upfront payment | None for the covered amount | Pay-up front and then claim later. |
Approval timing | Before planned admission, or within 24 hours of emergency | On document submission, after getting discharge. |
Best suited to | Hospitals listed near to employees. | Employees in areas with no network hospital near to their location. |
Documents | ID card or E-Cards and pre-authorisation form | Original bills, discharge summary, reports, claim form |
Can Group Health Insurance Cover Family Members In Other Cities?
Yes. If your group plan cover includes your family and they are not living in same city then also they will be covered. So, basically family members do not need to be in same location as per the employee office location.
A Worked Example Of A Remote Claim in Group Health Insurance
Let us consider an employee name Priya, a full-time employee who works remotely from Delhi and her company is based in Bengaluru. Her group health policy has a sum insured of Rs 5,00,000 per family with initial waiting period waived off and on pre-existing diseases and her policy provide cashless network across India.
So now Priya is admitted to a network hospital in Delhi for a planned surgery. Which costs Rs 3,20,000 and her hospital bill breakup looks like this:
Item | Amount |
|---|---|
Total hospital bill | Rs 3,20,000 |
Amount covered under cashless claim within sum insured | Rs 3,00,000 |
Amount which is non-medical or not-covered for example consumables are not covered | Rs 20,000 |
Amount paid by the insurer directly to hospital | Rs 3,00,000 |
Rest of the amount paid by Priya on her own | Rs 20,000 |
Priya received cashless treatment in her own city where she live. She never visited Bengaluru nor her company. Now, her remaining sum insured for rest of the year is Rs 2,00,000.
What All Should An Employer Set Up For a Remote Team when it comes to Group Health Insurance?
An employer getting a group health insurance for remote employee should consider following:
Network Hospital: Always confirm from the insurer or TPA whether they have a listed hospitals in the cities and towns where employees live and not just in metro cities.
Digital onboarding: Consider an online enrolment process for your employees so that they can submit their documents and if there policy also include dependents then their documents as well without doing any paperwork.
Digital ID cards: Make sure insurer is providing digital E-Card or ID cards to your employee so that they can easily claim from anywhere and without waiting for the physical documents
Addition and deletion of employe: Check if the insurer is providing a smooth endorsement process(add-del of lives).
Family definition: Before onboarding in group health policy discuss with your organisation whether they want to include dependents and parents or not.
Claim support: Make sure to have a support team, helpline or app so that an employee can reach out to any one of them during any problem regarding claims or any other queries regarding policy.
If an employee leaves a company, their cover also ends with that particular health policy. But some insurer provides an option that the employee can migrate or port their group health policy to an individual policy. So, make sure to confirm this option with your insurer.
Key Takeaways
Work from home employees or remote employees are covered under Group Health Insurance. All the terms and conditions are same for all employees whether they are from office or home because this cover doesn't depends on employee working location.
Group policy is valid PAN India. A remote can get treatment from any network hospital.
There are no initial waiting period and pre-existing disease waiting period is also waived off. Your covers starts from day one.
At a network hospital cashless treatments are applicable. If employee went to any non-network hospital then in that case they can apply for a reimbursement claim.
If family is also covered in the policy then they are also covered regardless which city they live in.
There is a specific category which is not covered in this policy like freelancers, contractor, usually those who are not on payroll of the organisation. They can be covered but it depends on insurer.
When employment ends group policy cover also ends. But there are few insurers which provide an option to switch your policy from group to individual.
An employer should always check the network hospital density of the insurer in actual cities where employee's are based and all kind of digital benefits so, that they claim easily from their particular location.
Frequently Asked Questions
No. Terms and Conditions are same for every employee which is set by the employer while opting for a group policy from an insurer.
About the authors
Neviya Laishram
Written by · Senior Editor – Health, Life and Group Health Insurance Content at ACKOWith a journalism background, she brings 9 years of experience in strategising and editing health, life, and group health insurance content. Having written for magazines and digital publications, she combines research and editorial expertise to create credible, useful content for readers.
Nitesh Kapur
Reviewed by · Senior Director – Underwriting & Claims, Group Health Insurance at ACKOWith over 15 years of experience in health insurance underwriting, he has led group health insurance strategy, risk assessment, and policy design. He has held leadership roles at leading insurers, building risk frameworks, evaluating complex health risks, and strengthening underwriting standards.
