Advantages and Disadvantages on Group Health Insurance VS Individual Health Insurance

By | September 8, 2017

In this article we will explore the reasons that motivate employers to get group health insurance for employees and we will look at the advantages and disadvantages from both points of view.

Group Health Insurance VS Individual Private Health Insurance

Probably the most significant distinguishing characteristic of group insurance is the substitution of group underwriting for individual underwriting. In group cases, no individual evidence of insurability is usually required, and benefit levels can be substantial, with few, if any, important limitations.

Group underwriting normally is not concerned with the health or other insurability aspects of any particular individual. Instead, it aims to obtain a group of individual lives or, what is even more important, an aggregation of such groups of lives that will yield a predictable rate of mortality or morbidity. If a sufficient number of groups of lives is obtained, and if these groups are reasonably homogeneous in nature, then the mortality or morbidity rate will be predictable. The point is that the group becomes the unit of underwriting, and insurance principles may be applied to it just as in the case of the individual. To assure that the groups obtained will be reasonably homogeneous, the underwriting process in group insurance aims to control adverse selection by individuals within a group.

In underwriting group insurance, then, certain important features should be present that either are inherent in the nature of the group itself or may be applied in a positive way to avoid serious adverse selection such as:

Insurance Incidental to the Group: The insurance should be incidental to the group; that is, the members of the group should have come together for some purpose other than to obtain insurance. For example, the group insurance furnished to the employees of a given employer must not be the feature that motivates the formation and existence of the group.

Flow of Persons through the Group: There should be a steady flow of persons through the group; that is, there must be an influx of new young lives into the group and an out flow from the group of the older and impaired lives. With groups of actively working employees, it may be assumed that they are in average health.

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Automatic Determination of Benefits: Group insurance underwriting commonly requires an automatic basis for determining the amount of benefits on individual lives, which is beyond the control of the employer or employees. If the amount of benefits taken were completely optional, it would be possible to select against the insurer because those in poor health would tend to insure heavily and the healthy ones might tend to elect minimum coverage.

As the group mechanism has evolved, however, insurers have responded to demands from the marketplace, particularly large employers, for more flexibility in the selection of benefits. This flexibility typically is expressed in optional amounts of life and health insurance in excess of basic coverage provided by the employer and in more health care financing choices. Also, increasingly popular cafeteria plans allow participating employees to select among an array of benefits using a predetermined allowance of employer funds. Individuals select, subject to certain basic coverage’s being required, a combination of benefits that best meet his or her individual needs.

Minimum Participation by the Group: Another underwriting control is the requirement that substantially all eligible persons in a given group be covered by insurance. In plans in which the employee pays a portion of the premium (contributory), generally at least 75 percent of the eligible employees must join the plan if coverage is to be effective. In the case of noncontributory plans, 100 percent participation is required. By covering a large proportion of a given group, the insurance company gains a safeguard against an undue proportion of substandard lives. In cases in which employees refuse the insurance for religious or other reasons that do not involve any elements of selection, this rule is relaxed.

Third Party Sharing of Cost: A portion of the cost of a group plan ideally should be borne by the employer or some third party, such as a labor union or trade association. The noncontributory employer-pay-all plan is simple, and it gives the employer full control over the plan. It provides for insurance of all eligible employees and thus, eliminates any difficulties involved in connection with obtaining the consent of a sufficient number of employees to meet participation requirements. Also, there is no problem of distributing the cost among various employees, as in the contributory plan.

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