Why do individual and group health plans have different claim experiences?


Health insurance serves as a critical safeguard against the unpredictable nature of healthcare costs in India. In this diverse insurance landscape, two primary categories stand out: individual health insurance and group health insurance. Despite their shared objective of providing financial protection for healthcare expenses, these two insurance types offer distinct claim experiences. In this comprehensive article, we will delve into the intricacies of why individual and group health insurance exhibit different claim experiences in India.

Understanding Individual and Group Health Insurance

Before we explore the factors contributing to contrasting claim experiences, it is essential to grasp the fundamentals of individual and group mediclaim policy:

Individual Health Insurance:

Individual health insurance is a policy that individuals purchase to secure coverage for their health-related expenses. These policies are personalized, catering to individual needs, and encompass various aspects of healthcare, including medical treatments, hospitalization, and other healthcare expenses. Premiums for individual policies are calculated based on several factors, such as the insured person’s age, medical history, and the selected coverage.

Group Health Insurance:

Group health insurance, on the other hand, is offered by employers or organizations to cover a defined group of individuals, usually employees and their dependents. These policies are designed to extend coverage to a broader pool of individuals under a single policy. Group health insurance premiums are typically shared between the employer and employees, with the employer often bearing a significant portion of the cost.

Now, let’s explore the reasons behind the distinct claim experiences in individual and group health insurance in India.

Risk Pool Characteristics

A fundamental reason behind the differing claim experiences lies in the composition of the risk pool. In individual health insurance, each policyholder is evaluated individually, and premiums are determined based on their specific health conditions and risk factors. This results in a highly diverse risk pool with varying levels of health.

In contrast, group health insurance typically covers a multitude of individuals from a single organization. This creates a more homogenous risk pool, as employees within the same organization often share similar demographics and health profiles. Consequently, risk is spread more evenly in group insurance, potentially leading to lower premiums and a different claim experience.

Underwriting and Pre-Existing Conditions

The underwriting process plays a significant role in shaping claim experiences. Individual health insurance policies often involve a comprehensive underwriting procedure, which includes assessing an applicant’s medical history and existing health conditions. Insurers may exclude coverage for pre-existing conditions or charge higher premiums to individuals with a history of illnesses.

In contrast, group health insurance policies typically undergo simplified underwriting. Coverage is often extended to all eligible employees without in-depth medical assessments. This means that pre-existing conditions may be covered from the outset, resulting in a more favorable claim experience for employees with such conditions.

Cost Sharing and Premium Contributions

Group health insurance often entails cost-sharing between the employer and employees. Employers usually subsidize a considerable portion of the premium costs, making healthcare more affordable for employees. This shared financial responsibility can lead to increased utilization of healthcare services, as employees are more likely to seek medical care when needed.

Conversely, individual health insurance policyholders bear the full weight of premium expenses, which can be substantial. This financial burden may lead some individuals to be more cautious about utilizing healthcare services, potentially influencing their claim experience.

Network and Negotiated Rates

Group health insurance plans frequently include negotiated rates with healthcare providers, resulting in cost savings for both the insurer and policyholders. These negotiated rates can translate into lower healthcare expenses for employees covered under group policies.

In contrast, individual health insurance policyholders may not have access to the same negotiated rates, and the scope of the provider network can vary. Consequently, they may incur higher healthcare costs, which can impact their claim experience.

Coverage Levels and Benefits

The extent of coverage and the benefits offered by individual and group health insurance policies can differ significantly. Group policies often encompass additional benefits, such as maternity coverage, dental care, or vision care, as part of the package. These additional benefits can enhance the overall claim experience for employees.

Individual policies, conversely, may offer more limited coverage options, contingent on the chosen plan. These differences in benefits can influence the types of claims made and the overall claim experience.

Claim Handling and Advocacy

The manner in which claims are handled and settled can vary between individual and group health insurance. Group policies frequently feature dedicated human resources teams or insurance advisors who assist employees in understanding the claims process and resolving issues.

In contrast, individual policyholders may need to navigate the claims process independently, which can be challenging, especially for complex or high-value claims. The level of support and advocacy provided can significantly impact the ease of claim settlement and the overall claim experience.

Portability and Continuity

Group health insurance is often linked to employment. When employees change jobs or retire, they may lose access to their group health insurance benefits. This lack of portability can disrupt the continuity of coverage and affect the claim experience during transitions.

Individual health insurance policies offer more portability, enabling policyholders to retain coverage even when changing jobs or retiring. This continuity of coverage can lead to a more stable and predictable claim experience for individuals.

Selection Bias and Adverse Selection

Selection bias and adverse selection can influence the claim experience in individual health insurance. Individuals with pre-existing health conditions or higher healthcare needs may be more inclined to purchase individual policies, recognizing their need for extensive coverage. This phenomenon, known as adverse selection, can lead to higher claims and potentially result in higher premiums in the individual market.

Group health insurance plans, conversely, typically do not suffer from adverse selection to the same extent. Coverage is extended to all eligible employees, creating a broader risk pool that helps mitigate the impact of adverse selection and fosters a more stable claim experience.

Claim Process in Individual and Group Health Insurance in India

These insurance types differ not only in their scope but also in how claims are processed. Below, we elucidate the claim processes for both individual and group health insurance in India.

Individual Health Insurance Claim Process:

The claim process for individual health insurance policies in India follows a structured series of steps to ensure policyholders receive prompt support and reimbursement for medical expenses:

  1. Notification of Claim:

When a policyholder needs medical treatment, it is imperative to notify the insurance provider promptly. This notification is typically expected within a predefined timeframe, often within 24 to 48 hours of hospitalization or commencement of treatment.

  1. Pre-Authorization (if applicable):

In certain scenarios, especially for planned hospitalizations or non-emergency treatments, policyholders must seek pre-authorization from the insurer. This involves the submission of relevant medical documents and treatment plans for approval.

  1. Hospitalization and Treatment:

After obtaining pre-authorization (if required), the policyholder proceeds with hospitalization and medical treatment as advised by their healthcare provider.

  1. Documentation:

Methodical record-keeping is pivotal in the claim process. Policyholders are advised to maintain original bills, invoices, medical reports, prescriptions, and other pertinent documents related to the treatment. These documents serve as crucial evidence during the claim submission.

  1. Claim Submission:

Subsequent to receiving treatment, policyholders are required to submit a duly filled claim form along with the supporting documents to the insurance company. The claim form can typically be obtained from the insurer’s website or customer service.

  1. Claim Assessment:

The insurer’s claims department meticulously reviews the submitted documents to evaluate the claim’s validity. In some cases, investigations may be conducted to corroborate the information provided.

  1. Approval and Payment:

Once the claim is verified and approved, the insurer initiates the payment process. Policyholders receive reimbursement for the eligible expenses, with funds transferred directly to their bank account or disbursed via a check.

Group Health Insurance Claim Process:

Group health insurance, owing to its collective nature, generally features a more streamlined claim process:

  1. Notification to Employer/HR:

When an employee covered under a group health insurance policy requires medical attention, they are typically required to inform their employer or the HR department, in accordance with the organization’s policies. Employers often play a pivotal role in facilitating the claim process for their employees.

  1. Hospitalization and Treatment:

Following the requisite approvals, employees proceed with hospitalization and medical treatment, adhering to their healthcare provider’s recommendations.

  1. Documentation:

Similar to individual health insurance, meticulous record-keeping is essential. Employees are advised to maintain original bills, invoices, medical reports, prescriptions, and other pertinent documents pertaining to the treatment.

  1. Claim Submission:

The employee submits the necessary claim documents to their employer or HR department, who, in turn, forwards the claim to the insurance company on behalf of the employee

  1. Claim Assessment:

The insurer’s claims department reviews the submitted documents and assesses the claim’s validity, following procedures akin to those employed in individual health insurance.

  1. Approval and Payment:

Upon verification and approval of the claim, the insurer processes the payment. Reimbursement is typically made to the employer or organization, who subsequently disburses the funds either directly to the employee or to the healthcare provider.


In India, individual and group health insurance represent pivotal components of the healthcare financing landscape, each characterized by distinct features and claim experiences. The discrepancies in claim experiences stem from differences in the composition of the risk pool, underwriting processes, cost-sharing dynamics, coverage levels, and other factors. Comprehending these distinctions is vital for individuals and employers when selecting the most suitable health insurance option. 


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