ModrinumGroup health
Three policies, one member master, one desk
Most employers we take on carry group mediclaim, group personal accident and group term life. Often the three sit with two insurers and one third-party administrator, and each holds a slightly different list of who is covered. The first job is to make those lists agree. The rest of the year is keeping them that way.
What each policy actually does
Employees confuse them constantly, and so do the reimbursement forms. This is the split we print on the plan summary handed out at enrolment.
| Cover | Pays for | Who is usually included | Where the claim goes |
|---|---|---|---|
| Group mediclaim (GMC) | Hospitalisation of 24 hours or more, listed day-care procedures, pre and post-hospitalisation windows, maternity where opted | Employee, spouse, up to two children; parents or parents-in-law where the employer has opted for a parental block | TPA — cashless at network hospitals, reimbursement elsewhere |
| Group personal accident (GPA) | Accidental death, permanent total and partial disablement; some plans add weekly compensation and ambulance | Employee only, in most Indian corporate structures | Insurer directly, with an FIR or post-mortem report where death is involved |
| Group term life (GTL) | A lump sum on death from any cause during employment, usually a multiple of annual salary | Employee only; nominee named at enrolment | Life insurer, on a nomination and death certificate file |
| Super top-up | Hospitalisation above an aggregate deductible equal to the base sum insured | Voluntary, employee-funded, elected at enrolment or on joining | Same TPA, but only after the base policy exhausts |
Sum insured and sub-limits
The number people quote in interviews is the sum insured. The number that generates complaints is the sub-limit underneath it. In our ticket data the loudest disputes are about room rent capping and maternity waiting periods, not about whether the cover is five lakh or seven.
A room-rent cap of one per cent of sum insured sounds harmless. On a five lakh policy it means five thousand rupees a day, and at most private hospitals along the EM Bypass a single-occupancy room is well above that. When the room is over the cap, many policies apply proportionate deduction to the whole bill, not only to the room charge — so a surgeon's fee and the operation theatre charge get scaled down too. That is the conversation nobody wants at discharge.
We model this before renewal rather than after a complaint. For each sub-limit we can show how many claims hit it last year, the average out-of-pocket that resulted, and what removing or raising it would cost in premium terms.
Sub-limits we always price out
- Room rent — capped rupee amount, percentage of sum insured, or single-private-room basis with no cap.
- ICU — usually double the room limit, sometimes uncapped.
- Maternity — separate limit for normal and caesarean delivery, plus the waiting period and whether the newborn is covered from day one.
- Ailment-wise caps — cataract, hernia, knee replacement, piles, often expressed as a fixed rupee ceiling.
- Pre and post-hospitalisation — commonly 30 and 60 days, with diagnostics before admission frequently missed by employees.
- Ambulance and day-care — small amounts, high ticket volume.
Corporate buffer, watched monthly
A corporate buffer is a shared pot the employer funds so an employee whose sum insured is exhausted can still be treated. It works until it is quietly emptied by three large claims in one quarter, and nobody notices until the fourth request is refused. We report buffer consumption every month against the balance, name the claims that drew on it, and flag when the remaining balance will not carry the policy to renewal. The decision to top it up is yours; the surprise is not.
Maternity and OPD, handled separately
Maternity
Maternity is the benefit most often misread. The three questions we answer at enrolment, in writing, are: what is the waiting period from policy inception, is it waived for the first policy year of a transferred group, and is the newborn covered from day one within the mother's sum insured or only after ninety days.
We also flag the practical detail nobody documents: pre-natal and post-natal expenses are excluded under most group maternity clauses unless the policy explicitly adds them, so the scans and consultations an employee pays for through the pregnancy are usually not claimable even though the delivery is.
Where a delivery is scheduled, our desk raises the cashless request a week before admission rather than on the morning, which removes the most common cause of a stressed call from a hospital lobby.
OPD and wellness
OPD benefits — consultations, diagnostics, dental, vision, sometimes an annual health check — are administered outside the hospitalisation policy in most Indian group programmes, either as a wallet with a rupee ceiling or as a reimbursement head processed by us.
We run the wallet: eligibility by grade, the claim window (bills older than ninety days are refused by most schemes, so we chase them before they age), the document standard, and a monthly settlement file that goes to payroll for credit with the salary.
Wellness fulfilment — annual health check camps, vaccination drives, a doctor-on-call line — sits with the same desk, because employees do not distinguish between the two and should not have to.
The member master is the whole job
Everything downstream — the e-card, the cashless approval, the renewal premium — is computed from one list. We treat that list as the deliverable.
- On appointment Three-way reconciliation We take the insurer master, the TPA master and your payroll register and reconcile them line by line. On a first pass we usually find between two and six per cent of records disagreeing: leavers still on cover, spouses added in an email that never became an endorsement, dates of birth that differ by a digit.
- Monthly, on a fixed date Addition and deletion file Joiners, leavers, marriages, births and dependant changes go across in one file on the same date each month, with the premium impact calculated before it is sent. Scattered weekly endorsements are the single biggest cause of the "my wife isn't on the policy" call in month three.
- Within two working days of acceptance E-card issue and reissue Cards go to the employee's work email and, where you allow it, their mobile. Reissue requests are handled by the helpdesk without routing through HR.
- Quarterly Data quality audit We re-run the validation set: missing dependant dates of birth, relationship codes that do not match gender, children above the exit age still on cover, employees appearing twice under two employee codes.
- Sixty days before renewal Renewal data set A frozen census, an age-band distribution, the claims MIS mapped to your member codes, and the loading estimate — ready before the insurer asks.
Ask us to reconcile one month
Send the current insurer master and this month's payroll register. We will return the differences, line by line, with the endorsement file already drafted. It is the fastest way to see whether the administration under your policy is doing what you assume it is.