There’s a hidden raise inside your CTC. It doesn’t show up on payday—it shows up when life goes wrong. That “raise” is your company’s insurance. Use it right, and you’ll save lakhs. Ignore it, and you’ll pay out of pocket for things your policy could’ve handled.
Who: Startups, MSMEs, enterprises.
Good news: most employers—tiny startups, busy MSMEs, and giant enterprises—now provide some insurance.
- Startups usually start with Group Health Insurance (GHI) for employees (sometimes for families too).
- MSMEs often add Group Personal Accident (GPA) and Group Term Life (GTL).
- Enterprises tend to offer higher sums insured, parental cover, wellness add-ons, mental health support, and better claim assistance.
Why you should care: These aren’t “HR extras.” They’re part of your pay. Knowing the limits, networks, and processes means fewer surprises, faster approvals, and less out-of-pocket grief.
Core covers: GHI, GTL, GPA
- GHI (Group Health Insurance): Pays hospital bills for covered illnesses/surgeries. Look for: Sum insured (e.g., ₹3–10L), cashless network hospitals, room-rent cap, maternity limits, any OPD/day-care coverage. Many group plans waive long waiting periods for pre-existing diseases—great for you.
- GTL (Group Term Life): If the insured employee passes away, a lump sum goes to the nominee. Action item: update your nominee today (HR portal/form). Typical cover is a fixed amount or multiples of salary.
- GPA (Group Personal Accident): Pays for accidental death or disability; often includes ambulance cover and partial disability payouts. Daily commuters, this one’s quietly powerful.
Watch-outs: Sub-limits, Deductibles/Co-pays, under-insurance (average clause), standard exclusions.
- Sub-limits: There’ll be Mini-caps inside the policy. Some of the classic traps are room rent cap (e.g., ₹5,000/day), maternity cap, and cataract per eye. Choose above the cap and you’ll pay the difference, Sometimes more due to proportional reductions.
Pro tip: Ask billing for a room within the cap; pick procedure packages within limits.
- Deductibles/Co-pays: Your share of each claim (e.g., 10% co-pay on parents).
Pro tip: Check if parents/older dependents have mandatory co-pays and budget for it.
- Under-insurance (Average Clause): If cover is too low, payouts can be proportionately reduced. In employee life: a ₹2–3L floater can vanish in a single hospitalisation.
Pro tip: If your company cover is modest, add a top-up or personal policy before you need it.
- Standard Exclusions: Cosmetic procedures, many dental/OPD items, fertility (unless included), injuries from risky acts, non-prescribed items, etc.
Pro tip: Read the exclusions page once and save a screenshot. So that the Two minutes now saves heartburn later.
Pricing factors: Claims history, employee mix, sums insured, and deductibles.
You don’t pay the premium, but these factors shape next year’s benefits:
- Claims history: High claims this year can mean higher premiums and future co-pays/caps.
- Employee mix: Older average age will be more dependents, so the cost will be higher.
- Sums insured: Bigger cover costs more (and protects more).
- Deductibles: Higher deductibles lower premiums (sometimes added quietly at renewal).
Why should you care?: Understanding these explains HR’s design choices and helps you vote for your must-haves (cashless network, adequate SI) over “nice-to-haves.”
Buy checklist:
You don’t buy the policy, but you use it. Here’s your claim-smart version:
- Risk map (personal): Parents covered? Maternity in 12–18 months? Chronic conditions? Decide if you need a top-up.
- Compare 2–3 (internally): Ask HR for the benefit summary and TPA/insurer app. If there’s an optional top-up, compare co-pays, room caps, maternity caps, and costs.
- Wordings/Exclusions: Scan exclusions & sub-limits once and save them.
- SLAs: What’s the cashless pre-auth time? Is there a 24×7 helpline? Dedicated employee desk?
- Claims process: Save your e-card, know network hospitals, and keep a 5-item claim kit: doctor prescription, reports, itemized bill, discharge summary, and payment proof (for reimbursements).
Red-flag check before admission
- Is your room within the rent cap?
- Is the hospital in-network (cashless)?
- Any procedure cap (maternity/cataract/hernia)?
- Do parents claims have a co-pay?
- Have you informed the TPA/insurer in time?
Three scenarios for better understanding
- Maternity: Cap is ₹60k, but your hospital bill is ₹1.2L. In this case, you pay ₹60k. So choose a package within the cap or plan the gap.
- Room cap: Cap ₹5k/day, but you choose ₹8k. In this case, many line items get proportionately cut. Ask for a cap-friendly room.
- Parent surgery: 20% co-pay on ₹3L ⇒ you pay ₹60k. Consider a personal cover for parents.
Final word
Update your nominee, save your e-card + helpline, know your caps/co-pays/exclusions, and add a top-up if your family’s risk is higher than the company cover. If anything’s unclear, ask your HR now, not from a hospital bed later.
