Group Health Insurance Policy Template for Employees

A group health insurance policy explains the medical insurance the company buys for employees and their families: who is covered, the sum insured, what is paid for, how to enrol dependants, how to make cashless and reimbursement claims and what happens at exit. The insurer's policy is the legal contract; this HR policy turns it into plain rules employees can follow when a family member is admitted to hospital.

When to use it: Use it when you buy group health cover for the first time, at every annual renewal, and whenever the insurer or the benefits change. HR drafts it with the insurance broker, finance approves the premium, and HR briefs employees at induction and after each renewal.

Group health insurance policy template

Copy the text below and replace everything in square brackets with your company details.

1. Purpose

This policy sets out the group health insurance [Company Name] provides to employees and their dependants, and explains enrolment, claims and cover at exit.

2. Scope

It applies to all employees on the company's rolls from the date of joining, including probationers. Employees covered under ESI [are also included in this policy / are not included] and continue to receive ESI medical benefits.

3. Coverage

Family covered: the employee, spouse and up to [2] children below [25] years of age.
Sum insured on a family floater basis: [₹3,00,000] for [grades 1 to 3], [₹5,00,000] for [grades 4 to 6] and [₹10,00,000] for [grades 7 and above].
Pre-existing conditions are covered [from day one, as negotiated in the current policy].
Maternity expenses are covered up to [₹Amount] for [the first two children].
Room rent is covered up to [1 percent of the sum insured] per day for a standard room.
Parents or parents-in-law may be added under voluntary cover of [₹Amount], with the premium paid by the employee through salary deduction.

4. Enrolment

New employees submit dependant details within [15] days of joining and are covered from the date of joining.
A new spouse or newborn child is added within [30] days of the marriage or birth, with the required documents.
Other changes are made only at the annual renewal.
Each employee receives an e-card and the TPA helpdesk details after enrolment.

5. Claims

Cashless: at a network hospital, show the e-card at admission. For planned admissions, the hospital seeks pre-authorisation [48] hours in advance.
Reimbursement: at a non-network hospital, pay the bills and submit the claim with original documents to the TPA within [30] days of discharge.
HR helps with escalations, but the insurer decides claims under the policy terms.

6. Exit

Cover for the employee and dependants ends on [the last working day or the last day of that month].
Where the insurer allows it, the employee may move to an individual policy by applying before the last working day.
Voluntary premium already recovered for the rest of the policy year is [refunded pro rata or not refunded], as stated in the enrolment form.

7. Confidentiality

Medical information in claims is handled by the insurer and the TPA. HR sees only what it needs to help with a claim and keeps it confidential.

8. Responsibilities

Employees: enrol dependants on time, keep e-cards handy and follow claim procedures.
HR: manage enrolment lists, additions and deletions with the insurer and help with escalations.
Finance: pay premiums on time and track the budget.

9. Review

HR reviews the cover, sum insured and claims experience with the broker [60] days before each renewal and explains any changes to employees before the new policy year starts.

What to include

Who is covered

List the family members covered and the age limits for children. Employees usually discover gaps in family cover only when someone is admitted, which is the worst moment to find out.

Sum insured by grade

State the family floater amount for each grade and whether parents can be added. Clear figures help employees decide whether they need their own top-up cover.

Enrolment windows

Set deadlines for adding dependants at joining, marriage and childbirth. A missed enrolment window is a common reason a dependant's claim is refused.

ESI-covered employees

Employees covered under ESI already receive medical benefits through ESI. Decide whether they are also in the group cover, and recheck ESI applicability as wages change.

Cover at exit

Say when cover ends and whether the employee can move to an individual policy. Someone leaving in the middle of treatment needs this information early.

The insurer's wording decides

Explain that the insurer's policy wording governs claims and the HR policy is a guide to it. This prevents promises in the HR policy that the insurer will not honour.

Common mistakes to avoid

Not removing leavers from the insured list, so premiums are paid for people who have left.
Missing the 30-day window to add a newborn, leaving the child uninsured.
Promising benefits in the HR policy that the insurer's policy does not cover.
Not explaining room rent limits until a claim is reduced.
Recovering voluntary parental premium without written consent.

Run it in ZeniaHR

The ZeniaHR self-onboarding link collects each joiner's family details, and the employee profile holds personal, address and nominee information, so HR has the data needed for enrolment with the insurer. The active and previous employee lists, with CSV export from the employee reports, give HR the joiners and leavers to send to the insurer each month. Voluntary parental premium can be recovered as an adjustment deduction in payroll inputs, and e-cards can be stored in employee documents.

Payroll Onboarding Employee documents

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Frequently asked questions

Is group health insurance mandatory for employers in India?

Group health insurance is generally a company benefit. For employees covered under ESI, medical benefits come through ESI under the Code on Social Security. Employers often add group health cover for all staff, or for those outside ESI, to attract and keep people.

Who is covered under group health insurance?

Usually the employee, spouse and children up to a set age, with parents or parents-in-law as an optional add-on. The exact family definition, age limits and sum insured are set in the insurer's policy and summarised in the company's HR policy.

How does a cashless claim work?

At a network hospital, the employee shows the health e-card at admission, and the hospital seeks pre-authorisation from the insurer or TPA, in advance for planned treatment. Once approved, the insurer settles the bill directly with the hospital, and the employee pays only for items the policy does not cover.

What happens to group health insurance after resignation?

Cover usually ends on the last working day or at the end of that month, as the policy states. Some insurers let the employee move to an individual policy if they apply before leaving. HR should tell departing employees the end date and any conversion option well in advance.