An employee may have Rs 5 lakh or even Rs 10 lakh of group health insurance through their employer and still discover that maternity expenses are covered only up to a much smaller amount. This is because maternity benefits can carry a separate sub-limit within the overall policy.
That difference matters when hospital expenses are high. A maternity limit that looked sufficient when the corporate policy was introduced may not be enough several years later, leaving the employee to pay the balance from savings.
The maternity limit is different from the total cover
The easiest way to understand the issue is to separate the overall sum insured from the maternity benefit. Suppose an employee has a Rs 5 lakh group health policy, but the maternity sub-limit is Rs 50,000.
If the admissible maternity bill comes to Rs 90,000, the employee cannot necessarily use the remaining Rs 4.5 lakh of the general health cover to pay the difference. If the policy caps maternity expenses at Rs 50,000, the remaining Rs 40,000 could fall on the employee, subject to the policy’s other terms.
IRDAI specifically advises policyholders to check restrictions such as sub-limits, deductibles, waiting periods and exclusions. The Customer Information Sheet also has to spell out important policy features, including sub-limits and waiting periods.
Waiting periods can change the picture
Maternity cover can also have a waiting period, depending on the employer’s group policy. This becomes particularly relevant when an employee joins a company while already planning a pregnancy.
Health insurance becoming active from the date of joining does not automatically mean that every benefit is available immediately. The maternity section of the policy needs to be checked separately.
Newborn expenses are another area that can be missed. A policy may provide newborn cover from birth, but the terms can specify a separate limit, eligibility condition or period of cover. Employees should not assume that all expenses for the baby will automatically be paid under the mother’s maternity benefit.
Why an old maternity limit can become a problem
Corporate health insurance is generally renewed periodically, but the maternity limit may not rise in line with the cost of treatment. If the limit stays at Rs 50,000 while the hospital bill reaches Rs 1 lakh, the gap becomes significant.
Take an illustrative bill of Rs 1.2 lakh against a maternity limit of Rs 50,000. The difference is Rs 70,000 before considering any expenses that the insurer may not admit under the policy.
The final out-of-pocket amount can be different because of exclusions, deductibles, co-payments or other restrictions. That is why looking only at the company’s headline sum insured can give employees a misleading picture of maternity protection.
What employees should check before renewal
The policy schedule and Customer Information Sheet are useful starting points. Check the maternity limit, whether normal and Caesarean deliveries have different limits, waiting period, pre- and post-natal expenses and the terms for newborn treatment.
It is also worth checking whether maternity cover extends to a spouse or other eligible dependants. The exact benefits depend on the group policy negotiated by the employer and insurer.
For an employee planning a family, the maternity sub-limit deserves as much attention as the overall health cover. A Rs 10 lakh policy may sound substantial, but a low maternity cap can still leave a sizeable bill to be paid personally.
FAQs
Does a Rs 10 lakh group health policy mean maternity expenses of Rs 10 lakh are covered?
No. Maternity treatment can have a separate sub-limit. The amount payable depends on the maternity benefit specified in the group policy.
Can a group health policy have a maternity waiting period?
Yes, depending on the policy terms. Employees should check the current policy schedule or Customer Information Sheet instead of assuming maternity treatment is covered immediately.
What happens if the maternity bill is higher than the sub-limit?
The amount above the applicable limit generally has to be paid by the employee, subject to other policy conditions. Deductibles, co-payments and non-covered expenses can add to the final amount.
The practical point is simple: the overall health insurance figure does not tell the full story. Before relying on employer-provided cover for childbirth, check the maternity limit and the conditions attached to it.
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