Group Health Insurance Terms Explained — Onsurity Learn

Group Health Insurance, explained for employers

Buying group cover for your team means meeting a lot of insurance jargon. Here are plain-English explainers of the terms that actually change what you pay and what your employees get.

Co-payment (Co-pay)

The share of a claim the employee pays while the insurer covers the rest.

Waiting Period

The time before certain conditions or benefits become claimable.

Room Rent Limit

The cap on daily hospital room charges — and why it matters.

Cashless Claim

How the insurer settles hospital bills directly at network hospitals.

Sum Insured

The maximum the policy pays for covered claims in a year.

Third-Party Administrator (TPA)

The intermediary that processes cashless approvals and claims.

Pre-Existing Disease (PED) Cover

How conditions employees already have are covered in group plans.

Section 80D Tax Benefit

The tax deduction on health-insurance premiums for employers and employees.

Network Hospitals

Hospitals with cashless tie-ups — how they work for your team.

Day Care Procedures

Treatments under 24 hours that are still covered by the policy.

Deductible

The fixed amount the insured pays before the insurer starts paying.

Sub-Limit

Caps on specific expenses within the overall sum insured.

Pre-Authorisation

The hospital-desk approval that unlocks cashless treatment.

Top-Up & Super Top-Up

Affordable extra cover above a deductible threshold.

Day-1 Cover

Group plans that cover employees from their very first day.

Restoration Benefit

Reinstates the sum insured after it is exhausted in a year.

No-Claim Bonus (NCB)

A reward for claim-free years — more cover or lower premium.

EDLI vs Group Term Life

The EPF-linked life cover, and how Group Term Life extends it.

Health Insurance Portability

Switching insurers while keeping accrued waiting-period credit.

Free-Look Period

The window to review and cancel a new policy for a refund.

Proportionate Deduction

How exceeding a room-rent cap scales down all linked charges.

Cashless vs Reimbursement

The two ways a health claim gets settled.

Grace Period

Extra days to renew without losing continuity benefits.

Domiciliary Hospitalisation

Cover for treatment taken at home when admission isn’t possible.

Pre & Post-Hospitalisation

Costs covered before and after the hospital stay.

Ambulance Cover

Reimbursement for ambulance transport to hospital.

Maternity Cover

Delivery and related costs in a group plan.

Newborn Baby Cover

Automatic cover for a newborn from day one.

AYUSH Cover

Cover for Ayurveda, Yoga, Unani, Siddha and Homeopathy.

Organ Donor Cover

Medical costs of an organ donor during a covered transplant.

Critical Illness Cover

A lump-sum on diagnosis of a listed serious illness.

Corporate Buffer

A shared top-up pool for employees who exhaust their cover.

Employer Contribution

The share of the group health premium the company pays for employees.

CD (Cash Deposit) Balance

The advance float the employer keeps with the insurer to fund additions and claims.

Endorsement (Additions/Deletions)

The formal record of mid-term joiner, leaver and detail changes on a policy.

Preferred Provider Network (PPN)

Hospitals empanelled at pre-negotiated package rates for tighter, cashless costs.

OPD Cover

Out-patient consultations, diagnostics and pharmacy.

Teleconsultation Benefit

Remote doctor consultations included in a group plan.

Preventive Health Check-up

Annual screenings offered as a wellness benefit.

Claim Settlement Ratio

The share of claims an insurer settled — a reliability proxy.

Incurred Claims Ratio

Claims paid vs premium collected — pricing sustainability.

Floater Sum Insured

A single cover shared across an employee and dependents.

Specific-Illness Waiting Period

Months certain ailments wait before they’re claimable.

Exclusions

The treatments and situations a policy won’t pay for.

Permanent Exclusions

What a policy never covers for the life of the plan.

Co-payment vs Deductible

Percentage share vs a fixed upfront amount.

Reimbursement Claim Process

Paying the hospital yourself and claiming it back.

Health Card (e-Card)

The digital ID that triggers a cashless claim.

Moratorium Period

After 60 months of cover, claims can’t be contested on non-disclosure.

Claim Intimation

How and when to formally notify the insurer of a hospitalisation.

Zone-Based Pricing

How premiums and co-pay vary by the city tier of your team.

Loading & Discounts

Extra premium or reductions based on claims and health profile.

Waiting-Period Buy-Back

An add-on that shortens or removes a waiting period.

Network vs Non-Network

Cashless at empanelled hospitals vs pay-and-claim elsewhere.

Restoration vs Super Top-Up

Two ways to extend cover after the base sum insured runs low.

Why Claims Get Rejected

The common reasons claims are denied — and how to avoid them.

IPD Full Form

In-Patient Department — hospitalisation cover, and how it differs from OPD.

IRDAI Full Form

The Insurance Regulatory and Development Authority of India — the sector’s regulator.

POSH Act — Full Form & Meaning

Prevention of Sexual Harassment: the 2013 Act, Internal Committee rules and employer duties.

ESIC — Full Form & Meaning

Employees’ State Insurance Corporation: the statutory health scheme for staff earning up to ₹21,000/mo.

GPA Sum Insured (CTC Multiple)

How group personal accident cover sets the sum insured as a multiple of annual CTC.

Permanent vs Temporary Disablement

How GPA cover defines and pays permanent total, permanent partial and temporary disablement.

Accidental Death Benefit (ADB)

The lump sum paid to an employee’s nominee if they die in an accident.

Weekly Disablement Benefit (TTD)

A weekly income benefit paid while an employee recovers from an accident.

Free Cover Limit (FCL)

The group term life sum assured each employee gets without any medical tests.

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