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General Advice for Health Insurance

When you decide to buy an insurance policy:
  • Check if the company selling the policy is registered with IRDA
  • Make sure you buy the policy through a genuine licensed agent or broker. Ask for an identity card or licence
  • You can also buy policies from the company directly
  • Read the policy brochure/ prospectus carefully and get to know what the policy covers and does not cover.
  • Why Buy Health Insurance ?
  • What Health Insurance to Buy ?
  • Health Insurance Dos and Don'ts

The term ‘Health Insurance’ relates to a type of insurance that essentially covers your medical expenses. A health insurance policy like other policies is a contract between an insurer and an individual / group in which the insurer agrees to provide specified health insurance cover at a particular “premium” subject to terms and conditions specified in the policy.

 Why Buy Health Insurance

A Health Insurance Policy would normally cover expenses reasonably and necessarily incurred under the following heads in respect of each insured person subject to overall ceiling of sum insured (for all claims during one policy period).

  • Room, Boarding expenses
  • Nursing expenses
  • Fees of surgeon, anesthetist, physician, consultants, specialists
  • Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radio therapy, cost of pace maker, Artificial limbs, cost or organs and similar expenses.

Sum Insured

The Sum Insured offered may be on an individual basis or on floater basis for the family as a whole.

Cumulative Bonus (CB)

Health Insurance policies may offer Cumulative Bonus wherein for every claim free year, the Sum Insured is increased by a certain percentage at the time of renewal subject to a maximum percentage (generally 50%). In case of a claim, CB will be reduced by 10% at the next renewal.

Cost of Health Check-up

Health policies may also contain a provision for reimbursement of cost of health check up. Read your policy carefully to understand what is allowed.

Minimum period of stay in Hospital

In order to become eligible to make a claim under the policy, minimum stay in the Hospital is necessary for a certain number of hours. Usually this is 24 hours. This time limit may not apply for treatment of accidental injuries and for certain specified treatments. Read the policy provision to understand the details.

Pre and post hospitalization expenses

Expenses incurred during a certain number of days prior to hospitalization and post hospitalization expenses for a specified period from the date of discharge may be considered as part of the claim provided the expenses relate to the disease / sickness. Go through the specific provision in this regard.

Cashless Facility

Insurance companies have tie-up arrangements with a network of hospitals in the country. If policyholder takes treatment in any of the net work hospitals, there is no need for the insured person to pay hospital bills. The Insurance Company, through its Third Party Administrator (TPA) will arrange direct payment to the Hospital. Expenses beyond sub limits prescribed by the policy or items not covered under the policy have to be settled by the insured direct to the Hospital. The insured can take treatment in a non-listed hospital in which case he has to pay the bills first and then seek reimbursement from Insurance Co. There will be no cashless facility applicable here.

Additional Benefits and other stand alone policies

Insurance companies offer various other benefits as “Add-ons” or riders. There are also stand alone policies that are designed to give benefits like “Hospital Cash”, “Critical Illness Benefits”, “Surgical Expense Benefits” etc. These policies can either be taken separately or in addition to the hospitalization policy.

A few companies have come out with products in the nature of Top Up policies to meet the actual expenses over and above the limit available in the basic health policy.

What Health Insurance to Buy

Exclusions

The following are generally excluded under health policies:
  • All pre-existing diseases (the pre-existing disease exclusion is uniformly defined by all non-life and health insurance companies).
  • Under first year policy, any claim during the first 30 days from date of cover, for sickness / disease. This is not applicable for accidental injury claims.
  • During first year of cover – cataract, Benign prostatic hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, piles, sinusitis and related disorders.
  • Circumcision unless for treatment of a disease
  • Cost of specs, contact lenses, hearing aids
  • Dental treatment / surgery unless requiring hospitalization
  • Convalescence, general debility, congenital external defects, V.D., intentional self-injury, use of intoxicating drugs / alcohol, AIDS, Expenses for Diagnosis, X-ray or lab tests not consistent with the disease requiring hospitalization.
  • Treatment relating to pregnancy or child birth including cesarean section
  • Naturopathy treatment.

Dos and Don'ts for Health Insurance

Healthcare costs are going up everyday and illness and hospitalisation affect our finances, our earning capacity and our daily lives,

Health Insurance: Some Dos and Don’ts

dos

When you buy a health insurance policy you should:

Know that there are restrictions on coverage

Pay special attention to terms and conditions in the policy like:

The clause excluding pre-existing diseases

Waiting period before certain diseases can be covered

Restrictions or limits on various expenses relating to hospitalisation

Co-payment, which means you have to share a part of the claim

Pre-conditions for renewal

Upper limits for age at entry and for renewal

Disclose details of all pre-existing health problems including:

Major ailments

Conditions like high blood pressure or diabetes

The company may want medical test reports depending on age at entry, you should comply with all procedures and documentation requirements

Check where and how the medical tests will be carried out

Check who should bear the cost for the tests

Pay the premium only after the insurer accepts your proposal

Renew the policy meticulously for the rest of your life

don’ts

Conceal facts or you could face a dispute at the time of a claim

Allow a gap of even one day in your policy renewal or your cover may be insufficient or useless

Overseas Health Policy: Dos and Don’ts

dos

Insure well ahead of your travel dates ensuring you have time for medical tests if required by the company

Ensure you cover your entire period of stay abroad and all the countries you will be visiting

Be aware of what your policy covers and does not cover. these policies cover not only hospitalisation but could also cover travel related risks like:

Loss of passport

Loss of cash

Loss of baggage and

Repatriation expenses

Disclose details of all pre-existing health problems including

Major ailments

Conditions like high blood pressure or diabetes

Comply with all procedures and documentation requirements the company may want including medical test reports depending on age at entry.

Check where and how the medical tests will be carried out

Check who should bear the cost for the tests

Pay the premium only after the insurer accepts your proposal

don’ts

Conceal facts or you could face a dispute at the time of a claim