Group Health Insurance Glossary

Group Health Insurance can be compared to attempting to read a foreign language, at times. With all the jargon, abbreviations and technical clauses, even the simplest Group Health Insurance Policy looks intimidating. Here is where this Group Health Insurance Glossary will come in handy. It can just be your all-in-one guide to understanding the terms that matter.

Whether you are an HR manager, a business owner, or an employee attempting to comprehend your benefits, the following A-to-Z glossary will help you decipher the lingo. The entries provide you with a two line definition that is clear enough to be understood but detailed enough to add value.

So, here we go, A to Z.

A 

1. Accidental Coverage – Group medical insurance protection that covers medical expenses and hospitalization arising from accidents.
   
2. Admissible Claim – A claim that qualifies for settlement under the terms and conditions of the group insurance policy.
   
3. Annual Premium – The total amount an employer pays yearly to keep the Group Health Insurance Policy active.
   
4. Ambulance Cover – Expenses for emergency ambulance services are reimbursed under this Group Health Insurance benefit.
   
5. Annuity – A regular payout option sometimes offered with certain Group Health Insurance policies  for long-term security.
   
6. Aggregate Limit – The maximum claim amount allowed under a group insurance policy across all insured members in a year.
   
7. Add-On Covers – Extra benefits that can be added to a basic group insurance policy, such as maternity or dental cover.
   

B 

1. Beneficiary –An individual who is entitled to get the benefits according to the policy, mostly the insured or his/her nominee.
   
2. Balance Sum Insured – It is the amount of the coverage that is left after making partial claims.
   
3. Bonus (No-Claim Bonus) –This is a bonus offered in terms of an augmented sum insured in case no claims are made during a policy year.
   
4. Break in Policy – The lapse in insurance policy coverage due to non-payment of premiums on time.
   
5. Basic Coverage – The standard medical and hospitalization benefits that the policy offers to an individual or a group of people.
   
6. Bed Charges – This is the daily rate of a hospital bed that the insurer will cover.
   
7. Benefit Limit – The maximum allowable amount payable under specific heads in the group medical insurance policy (such as maternity or daycare).
   

C 

1. Cashless Hospitalization –A facility in which the insured group of people receive care with no upfront payment; the insurance company pays directly to the hospital.
   
2. Claim Settlement Ratio – It is a percentage which indicates the number of claims that the insurer has paid out against the number of claims that the insurer has received.
   
3. Co-payment –A payment arrangement where a claim is shared between the insured and the insurer with the insured having to pay a given percentage and the insurer paying the remaining portion of the claim.
   
4. Coverage Period – The duration for which the Group Health Insurance Policy offers active protection.
   
5. Critical Illness Cover – This add-on is meant to cover illnesses that are life threatening such as cancer or heart disease.
   
6. Claim Form –It is a form that is completed by an insured member to seek reimbursement or cashless treatment.
   
7. Corporate Floater – A single sum insured that is shared among all the employees under the group insurance policy..
   

D 

1. Daycare Procedures –Procedures that do not take more than 24 hours of hospitalization, such as cataract surgery.
   
2. Deductible –This is the amount of money the insured has to pay before the insurance company initiates a claim payment.
   
3. Dependents –Family members (spouse, children, in some cases parents) that are covered by an insurance policy of an employee.
   
4. Domiciliary Treatment –Medical treatment administered at home, where hospitalization is not available but medically necessary.
   
5. Death Benefit – A lump sum paid to the nominee if the insured passes away under accidental cover.
   
6. Diagnostic Tests – Pathology or imaging tests covered if prescribed as part of treatment.
   
7. Dental Cover – An optional benefit that pays for dental treatments, subject to the Group Health Insurance Policy  terms.
   

E 

1. Eligibility Criteria – Conditions defining who can be covered under the Group Health Insurance Policy.
   
2. Exclusions – Treatments or conditions not covered by the insurance policy, like cosmetic surgeries.
   
3. Emergency Hospitalization – Urgent medical admission covered by the Group Medical Insurance Policy without prior approval.
   
4. Endorsement – Any modification or addition made to the existing Group Insurance Policy terms.
   
5. Employee Assistance Program (EAP) – Wellness benefits like counseling or stress management often included in modern group health insurance policies.
   
6. Extension Benefits – Coverage that continues for a short period even after leaving employment, depending on the Group Insurance Policy.
   
7. Employer Contribution – The share of the premium paid by the employer on behalf of employees.
   

F 

1. Family Floater – A single sum insured that is shared by all the members of an employee’s family.
   
2. First-Year Exclusion – Certain conditions that are not included during the first year of the policy.
   
3. Free Look Period –This is a limited period (in most cases 15 days) to consider the policy and cancel it in case of dissatisfaction.
   
4. Fixed Benefit – This is a lump sum that is paid on diagnosis of some conditions irrespective of the actual costs.
   
5. Form 64VB – A regulatory form that proves that the premium is paid prior to issuing the policy.
   
6. Future Renewals – The right to renew the coverage with new terms each year.
   
7. Fraudulent Claims –False claims, which, in case of detection, may result in denial of benefits and cancellation of the policy.
   

G 

1. Group Policy –A single master insurance policy that applies to many employees in one insurance contract.
   
2. Grace Period – Additional days granted beyond the premium due date in order to keep the insurance policy alive.
   
3. Guaranteed Renewal –This is a promise that the policy could be renewed without re-examinations of the medical conditions.
   
4. Grievance Redressal –A formal procedure of addressing the complaints of the policyholders against the insurer.
   
5. Government Hospitals –These are public sector hospitals. In some of these, claims can be made cashless with insurance tie-ups.
   
6. Group Size Requirement –The minimum number of members to qualify for group medical insurance coverage.
   
7. Global Coverage –  This is an add-on that provides medical cover to treatment outside India.
   

H 

1. Hospitalization – Admission to a hospital for at least 24 hours, unless it’s a daycare procedure.
   
2. Health Check-up Benefit – Free or subsidized medical tests offered periodically under group health insurance policies.
   
3. Home Nursing Benefit – Reimbursement for professional nursing care given at home post-hospitalization.
   
4. High Deductible Plan – A group medical insurance plan with lower premiums but higher out-of-pocket expenses for claims.
   
5. HMO (Health Maintenance Organization) – A network-driven health plan with limited hospital choices.
   
6. Health Card – An ID card issued to the insured group of people for cashless treatment at network hospitals.
   
7. Hospital Daily Cash – A fixed per-day cash benefit provided during hospitalization.
   

I 

1. Insured Member – Any employee or dependent covered under the Group Health Insurance Policy.
   
2. Inpatient Care – Medical treatment requiring hospitalization for more than 24 hours.
   
3. ICU Charges – Expenses related to intensive care unit stays, covered within the Group  Insurance Policy limits.
   
4. Indemnity Plan – A plan that reimburses actual medical expenses incurred by the insured.
   
5. Illness Definition – A medically diagnosed condition that requires treatment, as per policy wording.
   
6. Insurer – The insurance company providing the group health insurance cover.
   
7. IRDAI (Insurance Regulatory and Development Authority of India) – The regulator governing health insurance policies in India.
   

J 

1. Joint Coverage –Insurance that jointly covers the employees and their dependents.
   
2. Judicial Remedy – Legal action that can be taken by employees in case claims are not fairly addressed.
   
3. Job Loss Extension –It is a temporary extension of coverage under some group policies, even after termination of employment
   
4. Jurisdiction Clause –The legal place where any disagreement in the policy will be resolved.
   
5. Joint Policyholder –The policy is held jointly by two bodies (such as employer and employee unions).
   

K 

1. Key Employee Cover –Special coverage that is provided to critical employees in an organization.
   
2. Known Conditions – Preexisting medical conditions reported when the policy is issued.
   
3. Kaplan-Meier Survival Rate – A statistical application (occasionally used in actuarial health analysis).
   
4. KYC (Know Your Customer) –A regulatory obligation to check identity prior to granting policies to the insured.
   
5. Kidney Dialysis Cover – A daycare procedure that is covered on most group health plans.
   
6. Key Benefits Document –A one-page sheet that summarizes key aspects of the policy.
   
7. Knee Replacement Cover – Coverage provided for joint replacement surgeries under hospitalization.
   

L 

1. Loading – An additional premium charged as a result of increased risk profiles.
   
2. Long-Term Policy – A policy that has a duration longer than the standard policy of one year.
   
3. Lapse of Policy – This occurs where the coverage ceases due to non-payment of premium.
   
4. Legal Liability –The liability of the Employer to offer coverage as outlined in the labor laws or agreements.
   
5. Loyalty Benefit –This is an extra benefit to employees who remain longer with the organization.
   
6. Low Claim Bonus –An incentive in certain plans to keep claims to a minimum.
   
7. Limit Per Claim – The maximum insurance claim amount payable per hospitalization.
   

M 

1. Maternity Benefit – Coverage for delivery, pre- and post-natal expenses.
   
2. Mediclaim Policy – Another name for health insurance coverage in India.
   
3. Medical Underwriting – Risk assessment done before issuing the group medical insurance policy.
   
4. Maximum Renewal Age – The upper age limit up to which the group health coverage can be renewed.
   
5. Mental Health Cover – Inclusion of psychiatric treatments and counseling sessions to a group insurance policy.
   
6. Mid-term Inclusion – Adding new employees or dependents during the Group Health Insurance Policy period.
   
7. Mobile App Access – Digital tools provided by Group Health Insurance Policy providers for claims and policy tracking.
   

N 

1. Network Hospitals – Partner hospitals where cashless treatment is available.
   
2. Nominee – A person designated to receive benefits in case of the insured’s death.
   
3. Non-Payable Items – Expenses like gloves or bandages that are not reimbursed by the insurance policy.
   
4. No-Claim Certificate – A certificate showing that no claims were filed in a policy year.
   
5. Notification of Claim – Informing the Group Health Insurance Policy provider promptly about hospitalization or treatment.
   
6. Non-Medical Expenses – Out-of-pocket costs not covered by the insurance policy, like registration fees.
   
7. Non-Disclosure – Withholding health information, which can lead to Group Health Insurance Policy claim rejection.
   

O 

1. Outpatient Care (OPD) – Treatments where hospitalization isn’t required, like consultations.
   
2. Organ Donor Cover – Expenses related to organ donation procedures covered by the Group Medical Insurance policy.
   
3. Out-of-Pocket Expense – The portion of medical bills not covered by the Group Health Insurance Policy.
   
4. Optional Covers – Extra benefits that can be purchased on top of standard Group Medical Insurance coverage.
   
5. Occupational Disease – Illness arising directly due to workplace conditions.
   
6. Outpatient Pharmacy – Medicines bought without hospitalization, sometimes reimbursed by a Group Health Insurance Policy.
   
7. Overseas Treatment – Medical expenses covered abroad, if the Group Health Insurance Policy allows.
   

P 

1. Premium – The amount paid to maintain the insurance policy.
   
2. Pre-Existing Disease (PED) – Health conditions that were in existence prior to joining the policy.
   
3. Pre-Authorization – Prior permission needed in regard to cashless treatment.
   
4. Portability – The right to move to other insurers without forfeiting benefits.
   
5. Post-Hospitalization Expenses –The medical expenses incurred after discharge, typically, from 60 to 90 days.
   
6. Policy Schedule – A comprehensive manual of the benefits, terms, and coverage.
   
7. Preventive Health Check – Routine health check-ups that have been covered to ensure that diseases are detected early.
   

Q 

1. Quotation – An estimate of the possible premium offered by the insurer , for the chosen coverage.
   
2. Qualifying Period –The time frame before the commencement of some benefits.
   
3. Quarantine Cover – Quarantine-related treatment coverage (newly introduced after COVID).
   
4. Quick Settlement –Insurance companies that provide faster settlement of smaller claims.
   
5. Quality of Care – A measure of how effectively health services meet the needs of insured.
   

R 

1. Reimbursement Claim – The insured pays upfront and later gets expenses reimbursed.
   
2. Room Rent Limit – The maximum daily hospital room rent covered by the policy.
   
3. Renewal – Continuation of the policy by paying the premium before expiry.
   
4. Risk Assessment – Evaluating health risks before fixing premiums.
   
5. Riders – Additional covers attached to enhance the base policy.
   
6. Restoration Benefit – Automatic reinstatement of the sum insured if it gets exhausted.
   
7. Referral Hospital – A hospital where patients are transferred for specialized care.
   

S 

1. Sum Insured – The maximum financial coverage available under the policy.
   
2. Sub-Limit – A cap on coverage for specific conditions or treatments.
   
3. Second Opinion Benefit – Coverage for consultation with another doctor before treatment.
   
4. Specified Disease Cover – Targeted coverage for diseases like cancer or diabetes.
   
5. Surgical Expenses – Costs of surgeries performed during hospitalization.
   
6. Spouse Coverage – Extension of benefits to an employee’s husband or wife.
   
7. Super Top-Up Policy – An add-on that enhances coverage after a deductible threshold.
   

T 

1. Third-Party Administrator (TPA) – A service provider that manages claims on behalf of insurers.
   
2. Treatment Package – A fixed-cost package for specific procedures, covered by the insurer.
   
3. Telemedicine – Virtual consultations with doctors, increasingly covered by group plans.
   
4. Tenure – The duration for which the insurance policy is valid.
   
5. Terminal Illness Cover – Benefits provided when diagnosed with incurable diseases.
   
6. Tax Benefit (Section 80D) – Premiums paid are eligible for tax deductions.
   
7. Top-Up Cover – Extra protection that kicks in once the base sum insured is used.
   

U 

1. Underwriting – The process of assessing risks before issuing the policy.
   
2. Unclaimed Bonus – Benefit enhancement if no claims are made in the policy year.
   
3. Umbrella Coverage – A single large cover that includes multiple risk categories.
   
4. Urgent Care – Emergency medical treatment requiring immediate attention.
   
5. Unlisted Hospitals – Hospitals not part of the insurer’s network, where reimbursement applies.
   
6. Upgrade Option – Facility to enhance coverage at renewal time.
   
7. Utilization Ratio – The percentage of sum insured actually used during the policy.
   

V 

1. Voluntary Deductible – A higher out-of-pocket amount chosen by insureds to lower premiums.
   
2. Vaccination Cover – Expenses for preventive vaccines covered under some plans.
   
3. Value-Added Services – Perks like wellness apps, diet consultations, or yoga classes.
   
4. Vision Care – Coverage for eye check-ups, lenses, or surgery.
   
5. Virtual Health Consultation – Online doctor consultations included in modern plans.
   
6. Voluntary Coverage – Optional enrollment for dependents, beyond mandatory employee coverage.
   
7. Vital Signs Monitoring – Remote health tracking supported in wellness-driven plans.
   

W 

1. Waiting Period – The initial time before certain benefits become available.
   
2. Wellness Program – Preventive initiatives like gym memberships or stress workshops.
   
3. Waiver of Premium – Premium payment is waived under specific conditions, like disability.
   
4. Workplace Injury Cover – Protection against medical costs from workplace-related accidents.
   
5. Worldwide Emergency Cover – Emergency coverage across borders for employees.
   
6. Withdrawal of Policy – When an insurer discontinues a product line altogether.
   
7. Wellness Incentives – Rewards for employees adopting healthier lifestyles.
   

X 

1. X-Ray Cover – Imaging costs covered under diagnostic expenses.
   
2. X-Factor Risks – Unexpected risks like pandemics sometimes included under special clauses.
   
3. X-Linked Disorders – Rare genetic conditions occasionally included under specific plans.
   
4. Ex-Gratia Settlement – Claim settled at insurer’s discretion, even if not strictly covered.
   
5. Extra Premium – Additional premium charged due to high-risk medical conditions.
   

Y 

1. Yearly Limit – The maximum sum insured available in one policy year.
   
2. Yoga & Alternative Therapy Cover – AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) treatments covered by many insurers.
   
3. Year of Joining – Reference point used for eligibility and dependent inclusions.
   
4. Young Employee Benefits – Lower premium rates for younger workforce groups.
   
5. Yield Ratio – Insurer’s measure of claims vs. premium income.
   

Z

1. Zone-Based Premium – Premiums vary depending on the city/tier of the insured’s workplace.
   
2. Zero Depreciation Cover – Claims paid without factoring depreciation on medical equipment.
   
3. Zonal Coverage Restrictions – Coverage limited to specific regions, as defined by the insurer.
   
4. Zero Co-payment Plan – Plans where employees don’t need to share treatment costs.
   
5. Z Benefit Rider – An add-on designed to extend comprehensive coverage under group insurance.
   

Final Thoughts

Group health insurance is not all about paperwork but about people. Employees desire clarity and employers desire efficiency. When you are familiar with these terms, you fill the gap between confusion and assurance.

From accidental cover to zero co-payments, this Group Health Insurance Glossary will help you navigate through the jargon. Being aware of the following terminologies can help to make health insurance less of a nightmare, and more of a helping hand–whether you are a HR leader trying to explain policies to employees or a worker trying to understand your health card.