Most people believe that individual health insurance and group health insurance are essentially the same thing and that the only difference is that one is sold to individuals and that the other is sold to employers and other group organizations (such as clubs) to cover employees or members of the organization. In fact it is not quite as simple as that and individual and group health plans differ in a number of significant ways.
One of the most significant differences is that a group plan normally has fewer limitations and does not usually require those covered under the plan to provide proof of insurability. In other words the mere fact that you are a member of the group to which the plan applies means that you are eligible for cover.
Another important difference is that the contract for a group plan is made between the insurance company and the employer, union, trust, club or other sponsor and is not made directly with you as would be the case with an individual plan. This means that you have no power to negotiate changes to the plan to suit your own specific needs and that, where changes are made between for example your employer and the insurer, you have no real power to intervene.
The great advantage for most people of seeking health cover through a group plan lies in the fact that it has fewer limitations and is generally cheaper than an individual plan. However, one significant disadvantage is that your membership of the plan is tied to your membership of the group and, in the case of employment, a change in your employment status will affect your cover. For example, if you retire, are laid off, quit, or simply suffer a reduction in your hours you could suddenly find that you and your family lose your health insurance.
Now there is of course some protection for individuals who lose their employment through no fault of their own and the Consolidated Omnibus Budget Reconciliation Act (COBRA) will allow you to retain your group scheme cover for a while (typically 18 months) while you make alternative arrangements. The drawback of course is that you still have to pay for cover and this can be very expensive since you will have to pay not only the employee contribution which you were paying while in work, but also the employer’s contribution since you are no longer on the payroll. The benefits to which you are entitled under COBRA cover may also be reduced in many cases.
One other key difference between group and individual health insurance which is worthy of note here arises out of the Age Discrimination in Employment Act. This essentially means that, where a group plan is in existence covering a group of twenty or more employees, the employer must make insurance available to all employees, including their spouses and dependants. Accordingly, there is no age limit imposed for cover and this can be particularly beneficial to older employees.
These are of course only some of the main difference between group and individual health insurance but nonetheless represent a good starting point in helping you to decide between the two. Which you choose must of course be a personal decision but one important thing to remember is that health insurance becomes increasing difficult to get and more expensive the older you get and, even if you do decide to ‘shelter’ under an employer’s plan, the day will surely come when you will be on your own and forced to seek cover outside of your employer’s scheme.
Your employer’s scheme may be fine today but do not forget to view it not simply in terms of your present needs, but also in terms of your longer term needs.