Health Insurance

Key Benefits of Health Insurance Plans in India

Here's why investing in a health insurance policy is a smart move –

• Financial Security During Uncertain Times
  Life is unpredictable, and emergencies can strike at any time. With rising medical costs and soaring inflation, having a health insurance policy as your safety net becomes crucial. It helps you prioritise your health and recovery without the added stress of exorbitant medical bills.
   
• Preserves Your Savings
  In life, maintaining your financial resilience is a key aspect, especially when you face unforeseen healthcare expenses. A health insurance policy can protect you from the financial burden of exhausting your savings during a medical emergency. It safeguards your hard-earned money from being consumed by medical bills and allows your savings to fulfil their intended purpose. In short, the health insurance policy helps mitigate the escalating costs of healthcare, offering peace of mind to focus on recovery.
   
• Convenience Of Cashless Claim
  When you receive treatment at a network hospital affiliated with your insurer, you can take advantage of the cashless claim benefit. This arrangement ensures that all financial transactions take place between the hospital and the insurer. And, your only responsibility is covering any unapproved expenses. This cashless claim process eliminates the need for you to arrange for cash to settle medical bills and get them reimbursed later, ensuring a stress-free experience.
   
• Fostering Early Disease Detection for Optimal Health
  According to WHO, 27.5% of individuals worldwide do not meet the physical activity standards. An increase in lifestyle diseases among those under 45 is attributed to sedentary lives and various other contributing factors. If you happen to fall in this age category, you may be particularly vulnerable to ailments like obesity, diabetes, heart disease, respiratory issues, etc. These diseases are driven by factors like stress, pollution, poor dietary habits, an undisciplined lifestyle, excessive technology use, etc.
  
  To safeguard your well-being, it becomes imperative to embrace healthy practices and secure a comprehensive health insurance policy. Moreover, you should verify whether your policy extends coverage to routine check-ups. This proactive step ensures the timely detection of latent health conditions, paving the way for more effective and impactful treatment.
   
• Protects Your Family
  If you have loved ones and want to shield them from exorbitant medical costs, then investing in a family floater health insurance policy is essential. It is a smart choice that offers a single sum insured for everyone – from your parents and children to your spouse and other family members. This way, you ensure they get top-notch medical care without worrying about the expenses.
   
• Combats Rising Medical Costs
  The Health Report of Corporate India 2023 says that India faces one of the highest medical inflation rates in Asia, soaring to 14%. With advancements in medical technology, the cost of treatments has become substantial. Medical expenses include costs associated with ambulance services, tests, consultations, room charges, etc., which can accumulate quickly and put a strain on your finances. To efficiently tackle this, having a health insurance policy with adequate coverage becomes essential. It not only shields you from the stress of medical bills but also helps you stay ahead of medical inflation.
   
• Enjoy Tax Benefits
  According to Section 80D of the Income Tax Act of 1961, you can get claim deductions on the premiums paid for health coverage covering yourself, your spouse, kids, and parents - up to limits specified.
   

Benefits of Buying Medical Insurance at an Early Age

Listed below are some of the advantages of purchasing your health insurance policy early –

• Diseases Can Strike Anyone
  Contrary to the common belief that a health insurance policy is only essential in older age or when health concerns arise, the reality is actually different. A recent study says that approximately 500 million people are estimated to have vision problems in India. By 2030, it will affect approximately 40% of the urban youths.This is why waiting until you are older or prone to illnesses may not be the most strategic approach.
   
• Avoiding Waiting Periods
  Many health insurance plans come with waiting periods for pre-existing conditions. These waiting periods can become a hiccup when attempting to secure coverage later in life. Opting for the health insurance policy at an early stage allows you to overcome serving these waiting periods again, ensuring immediate and comprehensive coverage.
   
• Fewer Rejection Chances
  When you are young, you are healthier and less prone to medical issues. However, as you grow old, it can lead to a more stringent underwriting process for health insurance. While it may be challenging to secure affordable coverage, the likelihood of a health insurance policy rejection remains minimal during this phase.
   
• Medical Checkups May Not Be Needed
  Insurers mostly do not mandate extensive medical examinations when you are young. Mandatory check ups commonly kick in for those above 45 years. However, the associated conditions may vary between insurers.
   
• Shielding Long-Term Investments
  A health insurance policy serves as a protective barrier for your long-term investments. When you have medical coverage in place, your financial investments and assets face minimal risks from unforeseen health-related needs.
   
• Comprehensive Coverage for Financial Well-Being
  Early investment in a health insurance policy proves to be a valuable investment to your overall financial well-being. It provides extensive coverage, a safety net against unforeseen medical expenses, and ensures you don’t waste your hard-earned savings should something unfortunate happen. By securing your health early on, you not only protect your physical well-being but also strengthen the foundation of your financial security.
   

Eligibility Criteria to Buy Health Insurance

A health insurance policy plays a key role in managing healthcare costs and securing your finances during medical emergencies. But here’s the catch – the health insurance policy is available to only those who meet the eligibility criteria –

Age Restrictions
Most of the health insurance plans are available for individuals within a designated age bracket, spanning from infancy to a certain age. For grown-ups, the entry age could be anywhere from 18 to 65 years, depending on the policy. Some insurers even let you get the policy until you are 99 years old. Children have to be under a specified age range as well, starting from as early as 90 days old up to 18 or 25 years old or even more, depending on the policy. And, there are other special plans that provide coverage specifically for seniors above 65 years of age.

You should remember that these age limits can differ between insurance companies and policies. Hence, you need to check with your insurer regarding the specific eligibility requirements.

Medical History/Pre-existing Conditions
Your health history is a key factor in determining if you qualify for the health insurance policy. This is because insurance companies carefully verify your and your family's medical history to assess the potential risks you might bring as an insured person. While having a medical history or pre-existing conditions will not prevent you from getting coverage, they can have an impact on your premiums.

In some cases, specific conditions/diseases may be excluded from your policy as well. To find out if you have any pre-existing diseases, insurers may ask you to undergo health check-ups depending on your insurance plan –

• Some plans mandate check-ups for everyone, while others request such tests only if you are over a certain age, usually 45 or 50 or 65 years. The period can vary across insurers.
• In some cases, after the underwriter checks your proposal and documents, they may decide whether or not a medical test is necessary.

Other factors that influence the need for medical tests include the cover amount you need, your location, etc. For instance, if your cover amount is high, say above Rs 10 Lakhs, your insurer will not require you to undergo a medical test. You should be aware that insurers may also change their regulations from time to time. For instance, during the COVID-19 pandemic, health insurance plans were issued based on remote assessments rather than the traditional lab tests.

And, the specific tests needed may also vary based on factors like your sum insured, your age, the plan you intend to buy, etc. There are also instances where insurers offer you a policy without a check-up when you submit a declaration of your good health. However, it is recommended that you provide a full disclosure of your health history to avoid claims being rejected over uncertainties or minor issues.
 

Importance of Health Insurance Plans In India

In India, health insurance plays a crucial role in ensuring financial security and accessibility to medical care. The importance of health insurance plans in India cannot be overstated, particularly for the following reasons -

1. Copes With High Medical Costs
   In today’s world of emerging diseases and new medical technologies, the cost of quality medical care has increased. According to the 2019 Global Health Statistics published by the World Health Organization, 7 of the 10 leading causes of death in the world are non-communicable diseases. Such alarming stats highlight the impact and prevalence of non-communicable diseases on a global scale. New methods of drug development and efficacy increase the price of advanced treatment. This is why it is important to have a health insurance policy. It allows high medical costs to be managed more efficiently, allowing you and your family to have a healthier lifestyle.
    
2. Protects Your Family
   Prioritising the well-being of your family is of utmost importance. This is why it is vital to have a health insurance policy during times of unfortunate health issues. It allows you to provide necessary medical care to your loved ones, speeding up their recovery. By safeguarding your family's health through a health insurance policy, you not only prioritise their well-being but also gain peace of mind knowing that their medical needs are addressed efficiently.
    
3. Better Than A Healthcare Fund
   While having a healthcare fund is a smart way to save for future medical expenses, it's essential to understand that it cannot replace a health insurance policy. In the current scenario, the costs associated with medical and surgical procedures can be quite high, leaving healthcare funds insufficient to cover all your medical expenses.
    
4. Preserves Your Hard-Earned Savings
   Over the years you’ve worked hard to save for your future goals – whether it is for buying a house, funding your children’s education, hosting special events, assuring a secure retirement, etc. The weight of an unexpected illness on your savings can be daunting. This is where a health insurance policy acts as your shield, allowing you to manage medical expenses without draining your hard-earned savings. You can also avail of cashless treatment that frees you from the hassles of paying cash upfront and getting reimbursement later.
    
5. Early Buying Means More Benefits
   Health insurance plans usually require a medical examination prior to its issuance. It is important to note that some insurance companies mandate these tests after a certain age 45. However, this requirement can vary across insurers. The results of these tests are important in determining your eligibility for a health insurance policy.
   
   With age comes an increased chance of health issues such as diabetes, heart disease, respiratory diseases, etc. These health risks pose challenges in obtaining a health insurance policy. Even if you manage to get one, the premiums may be higher compared to when you were younger. Therefore, it is wise to buy the right health insurance policy while you are still young.
    
6. Enjoy Tax Benefits
   Section 80D of the Income Tax Act, 1961, offers tax exemptions for both premiums paid and payouts received. This applies to health insurance coverage for you, your spouse, dependent children, and parents. While tax benefits certainly contribute to increased savings, it's crucial to emphasise that the primary motive for investing in a health insurance policy should be to secure financial protection against medical expenses.
    

Why Should You Purchase Health Insurance?

• To Protect Your Family
  You want to protect your family at all costs and ensuring their health and well-being is your top priority. A comprehensive health insurance policy is one of the best ways to ensure your family's good health and financial security.

• To Combat Increasing Healthcare Costs
  Access to quality medical care has become a challenge for many people across the country - because of skyrocketing medical inflation. The cost of treatments, medication, equipment, consultations, etc. is rising continuously. These expenses might get pretty heavy on your pocket, especially if there’s a medical emergency. Health insurance can be a lifesaver for dealing with such a situation. It protects you and your family against exorbitant medical expenses.
   
• For Better Coverage Than A Healthcare Fund
  You may have saved up a healthcare fund as a backup to deal with any sudden healthcare costs and emergencies. But, this money may not prove to be a good enough shield when faced with the monstrous costs of medical treatments and hospitalisation! Quite literally. Especially in the case of preventative care and nuanced medical procedures. A single hospitalisation can even have the potential to wipe out your entire savings. You should ideally have both a healthcare fund and health insurance to ensure adequate coverage for any potential medical expenses.
   
• To Make The Most Of Your Youth
  Insurance providers generally assess your health based on the results of your medical tests. Some insurers may make medical tests mandatory after the age of 45. As you age, the risk of developing health issues increases, and insurance companies will factor this risk into their calculations when determining the premiums for your policy. By buying a suitable policy while you are young and healthy, you will be able to take advantage of lower premiums and better coverage.
   
• To Preserve Your Savings
  With a health insurance plan, you can rest assured that your medical bills are taken care of. This means that you don't have to worry about sacrificing your future goals or cutting into your savings to cover medical expenses. It can also save you time and effort, since many insurance companies offer cashless treatment at network hospitals, so you don't have to go through the process of filing for reimbursement.
   
• For Tax Benefits
  Health insurance offers various tax advantages. Under Section 80D of the Income Tax Act, 1961, premiums and payouts are exempt from taxation.
   

Things to Remember While Purchasing Health Insurance

It's important to keep certain things in mind when buying health insurance to avoid any sort of difficulties later on. Let’s have a look -

• Decide The Sum Insured
  The most important factor to consider while buying health insurance is the sum insured. It is the maximum amount the insurer will pay for the medical expenses incurred for any type of hospitalisation.
  Since medical inflation is on the rise, adequate coverage is crucial to deal with exorbitant healthcare costs. Make sure you choose a sufficient sum insured that can comfortably meet your medical needs.
  Secondly, as you get older, upgrading your health insurance coverage may prove to be challenging due to age and health factors.
  
  Thus, it is important to purchase a health insurance policy that is able to keep up with the increasing medical inflation and provide you with the coverage you need in your later years.
   
• Comprehensive Coverage
  Having comprehensive coverage will ensure that a majority of your medical expenses will be covered by your health insurance. Comprehensive coverage includes coverage for doctor visits, pre and post-hospitalisation costs, daycare treatment costs, ambulance fees, check-ups, etc. You can be sure that you will have access to the care you need with fewer out-of-pocket expenses.
   
• Affordable Premium
  The best health insurance plan should have comprehensive coverage and also reasonable premiums so that you don’t have to use up a huge chunk of your finances for paying premiums. You need to find the right balance between premium cost and coverage. It should be enough to cover your medical costs and shouldn’t hamper your present budget.
   
• Check If Hospitalisation Is Medically Necessary
  You can only get health insurance coverage if the hospitalisation/treatment is deemed 'medically necessary'. Hospitalisations and treatments are considered medically necessary if they meet the following 4 conditions:​​​​​

1. It is necessary to manage the illness or injury.
2. It provides safe, adequate, and appropriate medical care in terms of scope, duration, and intensity.
3. A medical practitioner unrelated to you recommended it.
4. The treatment complies with professional standards widely accepted in international medical practice.
5. A claim may be rejected by your insurer if the above conditions are not met.

• Check The Room Rent Limit
  A room rent limit is the limit up to which your health insurance will cover per-day hospital room charges. Room rent limits are included in most health insurance plans with a sum insured up to Rs. 5 lakhs.
  If you choose a room that has a room rent of more than what you’re eligible for under your health insurance plan, the insurer won’t only deduct the difference in room charges but will also proportionately deduct all associated medical expenses.
  
  So, check whether your policy has a room rent limit and try to buy a policy that does not impose such financial restrictions. If your policy has such a limit, you should plan to port to a policy without any limits.
   
• Check The Specific Disease Waiting Period
  A waiting period is a duration during which certain illnesses or treatments will not be covered. It applies even if you don't have these diseases at the time of buying the policy. Some insurers may apply a 2-4 year waiting period for treatments for specific diseases like hernia, slipped discs, sinusitis, knee replacement surgery, etc.
  Your insurer will not pay a claim for such diseases/treatments if the waiting period specified in your health insurance policy has not been completed. And, upgrades to your health plan will not cover these specific diseases/treatments during the waiting period.
   
• Check For Financial Limits On Specific Treatments/Procedures
  Some insurers may put a limit on certain diseases or treatments. With such limits, you may be forced to pay a significant amount even if you have adequate coverage.
  For instance, Monica buys a health insurance plan with a sum insured of Rs. 5 Lakhs. In the policy, the limit for hernia surgery is Rs. 50,000. Say she undergoes hernia surgery costing Rs. 1 lakh. In this case, the insurer will only pay Rs. 50,000 and the remaining Rs. 50,000 is her responsibility.
  To ensure you are not left with an unexpected expense, you should choose a health insurance policy that does not come with these restrictions.
   
• Keep An Eye On Copayment Clauses
  If you have a copayment clause in your health insurance policy, it can affect your claim. Health plans with copay clauses require you to pay a portion of the claim. The insurance company pays the rest. It is best to buy a policy without a copayment clause or with the lowest copay to avoid major expenses from your end.
   
• Assess The Treatment Costs Of Various Hospitals
  Hospitals do not have any rules in place when it comes to billing in India. They can charge different rates for the same treatment. And it may get exorbitant.
  An insurer primarily looks at the fee charged by similar-grade hospitals in a given area for a specific treatment. Consequently, insurers are able to ensure that they are not overpaying for services that can be acquired at more reasonable prices. They use reasonable and customary charges as a benchmark for determining what is considered a fair price for treatment. So, if you go to a hospital that charges more than what other hospitals in the same area charge, your insurer will only reimburse you for charges that are reasonable and customary.
   
• Non-Medical Expenses Coverage
  Health insurance does not provide coverage for non-medical expenses or the cost of consumables such as gloves, nebulization kits, oxygen masks, etc. So, these costs can add up quickly and can be a financial burden in the event of a hospitalisation. So, opt for consumables cover with your health insurance to cover such non-medical expenses.
   
• Fill In The Proposal Form Accurately
  The insurer agrees to assume the risk of lifelong hospitalisation or treatment expenses when it offers health insurance policies. Your proposal form serves as the basis for issuing you the policy. Therefore, it is important to ensure that all information you provide is accurate.
  If there are any incorrect details or concealment, it can lead to unnecessary complications if the insurer discovers them later. They may reject your claim and even cancel your policy.
  So, you should be honest and accurate on the proposal form and provide the insurer with details of any major injuries, illnesses, and surgeries you have had in the past.
   
• Keep Track Of The Policy Conditions
  Insurance companies are permitted to change policy benefits, conditions, and costs with the approval of the IRDAI. It is also possible for them to terminate your health insurance plan and migrate you to a different plan with different benefits.
  Any changes to the policy terms must be notified to you three months prior to the new terms taking effect. To ensure you stay informed of any changes, it is essential to provide your correct contact information to the insurer and make sure it is updated.
   
• Providing Correct Details To The Doctor
  As part of the hospitalisation process, the doctor will ask you about your past medical history, medications, allergies, etc. It is important that all these details are provided to the doctor carefully and accurately. During the course of treatment, doctors compile a case paper that contains details regarding the patient's past medical history, the year of diagnosis, medication, allergies, etc. These case papers will then be shared with the insurance company by the hospital. Hence, it is important to ensure that the case paper contains up-to-date and accurate information.
   
• Maintain Proper Documentation
  In order to file a claim for health insurance, you will need to submit various documents like doctors’ prescriptions, diagnostic reports, proof of payment, invoices, etc. If any document is missing, the insurer will deduct that expense before paying the claim.
  So, you should maintain a single folder for all your bills, receipts, and other documents. Furthermore, keeping a record of all your documents will save you time and effort when filing a claim. You should pre-number all invoices and receipts you receive from the hospital/doctor. This will make it easier to find the documents you need, so you can focus on the filing process and not waste time searching for them.
   
• Have A Look At The Insurers’ Claim Settlement Ratios (CSR)
  CSR refers to the percentage of claims settled against the total number of claims received by an insurance company in a financial year. It helps you gauge the insurer's worth. A company with a high CSR is more likely to settle claims, increasing the likelihood of your claim being approved.
   
• Check The Insurer’s Solvency Ratio
  The solvency ratio represents an insurance company's ability to meet long-term financial obligations and settle claims. It reflects the financial status of insurance companies. In accordance with IRDAI regulations, all insurance companies are required to possess a solvency ratio of 150%. A higher solvency ratio signals that a health insurance company is financially stable and has a higher proportion of assets. This means that even if there is a large claim, the company has sufficient financial resources to pay them off.
   
• Verify The Insurer’s IRDAI Approval
  The Indian Insurance Regulatory and Development Authority (IRDAI) regulates and develops the country's insurance industry. Insurance companies registered with IRDAI must comply with all of its rules and regulations and be transparent in their operations. In other words, you should always choose an IRDAI-approved company if you want to buy health insurance for yourself or your family - to ensure your hard-earned money doesn't go down the drain.
   

Health Insurance Policy Riders

Health Insurance riders, also called add-ons, give you the option to enhance your base health insurance coverage. These optional benefits offer extra protection in case of specific situations. Here are some of the riders available under a health insurance policy –

• Maternity Cover
  Some plans provide maternity benefits as an add-on. This coverage safeguards you financially during pregnancy and covers medical expenses up to specific limits in a policy year. It becomes especially valuable if you are planning to start a family. It helps ease the financial burden that comes with pregnancy and childbirth, letting you focus on your health and your newborn. You should also note that some insurers allow you to extend coverage to infants for a fixed period.

• OPD Cover
  Outpatient expenses (OPD) include costs associated with medical treatments and consultations that do not need hospital admission. These include regular check-ups, diagnostics, pharmacy costs, etc. These recurring expenses can drain your pocket. However, with an OPD add-on or rider, you can alleviate concerns about such expenses and focus on your health.
   
• Global Cover (Overseas Treatment) Cover
  The global cover takes your health insurance coverage beyond India's borders. In case you get diagnosed with a medical condition here in India that needs treatment abroad, your policy will cover the medical expenses during your overseas treatment, up to specified limits. This cover ensures peace of mind when you seek treatment outside your home country.
   
• Critical Illness Cover
  If you get diagnosed with a critical illness listed in your policy, the insurance company pays a lump sum amount as per the terms and conditions. These illnesses can include cancer, severe heart stroke, brain tumour, multiple sclerosis, and so on. If such diseases run in your family, a critical illness rider could be a smart addition to your health insurance policy. You should however remember that there might be a waiting period for this add-on.
   
• Personal Accident Cover
  The personal accident cover can act as a financial safety net in the event of an accident. This rider provides a lump sum amount if you meet with an accident that leads to disablement or fatality within a specific number of days of its occurrence.
   
• Room Rent Waiver Add-on
  In some health insurance policies, the room rent is usually limited to a specific amount. If you prefer a more expensive room, you will have to pay a proportionate share of the entire bill, not just the difference in room rent. However, with the room rent waiver add-on, you get a higher sub-limit or no limit at all. This means your insurance company covers the room rent, no matter the room type you choose.
   

Cashless Claim Process

Here are the steps involved in availing a cashless claim settlement -

Reconfirm If The Hospital You Have Chosen Has A Cashless Arrangement With Your Insurance Provider.

Some hospitals may have different arrangements for corporate policies and personal insurance policies - be aware of this difference.

• Carry a copy of your policy and take their confirmation of the same.
• Once confirmed, ask the hospital desk for a checklist of all the documents they will require of you for a smooth process.
• Further, check for any sub-limits for specific ailments in your policy. This will give you an idea of the additional costs you’d have to bear personally.

Submit A Pre-Authorization Request

Pre-authorization is the process by which the insurer approves to pay for costs associated with your medical visit.

• Inform the insurance desk at the hospital about the policy you hold, and submit all the documents they demand.
• You will be asked to fill up and sign a claims form, a part of which will be later filled by the doctor/hospital staff.
• The insurance desk will take the process ahead with the Insurance company or Third-Party Administrator (TPA) - the agent of the health insurance corporation.

Keep Emergency Money Handy

• In case your pre-authorization approval is delayed, or the treatment is urgent and cannot wait for the final approval, the hospital might ask you to make an advance payment.
• Always keep emergency money or an active payment method handy for such situations.
• This advance is later refunded (fully or partially) when the insurance company approves the cashless claim request.

Submit The Required Documents

• Policy copy or cashless card
• All past medical records leading to the hospitalisation
• KYC for the patient
• Police FIR (in case of accidents)

Take Care Of The Following Steps -

• Process The Paperwork In Advance
  In case of a planned hospitalisation, submit the form at least 3-4 days prior to the admission. If you are the patient, to prevent avoidable delays, send in a responsible family member to complete the paperwork before you get to the hospital. In case of emergency hospitalisation, submit the form within 24 hours of hospitalisation.
   
• Track The Progress
  Upon submission of the pre-authorization form, you can track the progress on the TPA app or website. Answer all queries raised by the insurer at the earliest, which will ensure an uninterrupted claim settlement. An insurance company can delay or reject an authorization, if the documents are not submitted or the queries are not answered. In such a case, you will have to go for the reimbursement process.
   
• Keep copies of all documents submitted
  Ensure that you have a soft-copy (or at least photocopies) of every document you submit, as the insurer might ask for them later.
   
• Track The Billing Everyday
  With a clear picture of how much the final bills could be, you can then either inform the insurer of any additional charges, or use another policy if the current coverage is insufficient.
   
• Keep A Record Of All Pre-Hospitalization Expenses
  Medical expenses incurred before the hospitalisation will have to be claimed separately with the insurer. Store all the original prescriptions, bills/receipts, reports (including films) that led to the hospitalisation, since these can be claimed separately. It is also important to have prescriptions from the first doctor you visited, with the problem that led to this hospitalisation. especially if they are from another hospital/clinic.
   
• Keep Medicine Bills After Purchase
  If you purchase medications at the hospital counter, even before getting discharged, they too will get covered under cashless claim.
   
• Be Prepared For The Final Billing

Once the doctor finalises your discharge date, check with the hospital insurance desk, and submit the final paperwork (including the final bill and discharge summary) to the insurance company. Do this as early as possible.

If any documents are still pending, the insurance company will notify you. Track the progress through the insurance company's online tracker, and submit the missing documents at the earliest. Once all the papers are submitted, it will usually take between 2 to 6 hours to receive an approval from the insurer.

In case the final approval does not arrive or is delayed, you may have to wait at the hospital, or pay upfront and claim the amount later as reimbursement.

• Learn About The Claim Approval Process
  As per the terms and conditions of your insurance plan, approved claims will show an account of the expenses approved and unapproved . You need to read through the claim settlement summary carefully. Expenses such as co-payment, proportionate deduction, exclusion for consumables, etc. need to be borne by you.

For example, if your insurance policy has a co-pay (or co-insurance) clause of 15% and your medical expenditure has amounted to Rs.60,000, you will have to pay Rs. 4,000 out of your own pocket, and the insurer will cover the remaining Rs. 56,000.

Hospitals may keep some deposit with them even after your discharge, as retention money, till they receive their payout from your insurer. Save this receipt and collect the refund once the payout has been made.
 

Reimbursement Claim Process

Reimbursement can be made in three situations -

• For the entire treatment: right from pre-hospitalization till post-hospitalization.
• In case of cashless claims: every cashless claim has a reimbursement component - for pre-hospitalization and post-hospitalization expenses.
• When one policy is used for a cashless claim and the remaining amount is claimed through reimbursement.

Whatever may be your situation, you need to go through the following steps -

Claim Intimation

• In case of any situation where you need to redeem a claim amount, notify the insurance company first. Call them on their toll-free number, or send an email/SMS to inform them about the hospitalisation, within 24 hours of the admission.
• Enquire about the timeframe within which you can submit the reimbursement claim after discharge, so you are aware of the deadlines.

Collecting And Maintaining The Documents

• The speed and success of your claim entirely depends on how well you can document the process and keep the records.
• Ask your insurer for a list of all the documents you need to submit for a successful claim, and start putting them together.
• From the date of discovery to the time of recovery - ensure that all documentation is properly collected and maintained.
• Include all documents - from doctor consultations, prescriptions, bills, receipts, test reports (including X Ray or MRI films) to pharmacy bills - and everything else in a secure folder.
• To keep a track of all the medical expenses, create an Excel sheet and fill up all the costs incurred - from consultation fees to the final room rent and discharge bill.
• Fill up the claim form carefully after reading it, and provide all the details correctly.

Documents Required To Make A Reimbursement Claim

• Health card or policy copy.
• Photo ID of the insured person
• Claim form - filled and signed. A part of this form has to be filled by the hospital with the treating doctor’s sign.
• All prescriptions for medicines, medical tests including prescriptions from the first doctor you visited, with a complaint leading to this hospitalisation in original.
• All pharmacy bills in original.
• All test reports, including films & CDs (Xray, MRI) in original.
• Hospital bill with patient details, including itemised bill in original.
• Discharge summary from the hospital in original.
• All other original bills before the hospitalisation associated with your treatment. The bills for expenses after the hospitalisation can be claimed separately after 60 days or the time mentioned in the policy.
• Your bank details, which can be provided through a cancelled cheque for NEFT transfer of your reimbursement. Note that insurers do not send cheques, they only make online transfers.
• In case of an accident, an FIR or a medico-legal certificate or a summary of the accident may be required.

Make A Duplicate Copy Of All The Original Documents You Submit To The Insurer, And Retain Them For Your Own Record.

• If the insurance company raises queries, you can present the copies of the documents submitted.
• Track the claim status on the insurance company's portal or app regularly to be aware of such requirements, and address them at the earliest.

Claim Settlement

• Your insurer will credit the amount to the bank account you provided while submitting your claim.
• They will communicate with you about the summary of deductions made. Go through the mails/sms you receive, and understand the deductions well.
• In case you have any doubt, you can duly raise a query with the insurance company.

It’s true that the final responsibility of claim settlement lies with the insurer, but as a policyholder, you can do your part to make things work out a bit faster and a lot smoother. It can be really overwhelming to take care of the claims process, especially if you are the patient. Therefore, sit with a family member, or a person you deeply trust, and go through the technicalities in advance. This article aims to be a helping hand and make the difficult times easier for you.
 

Types of Health Insurance Plans

• Individual Health Insurance
  Individual health insurance is tailored to the individual's specific needs and provides medical coverage that may be necessary for the individual's health and well-being. It covers medical charges such as surgery costs, pre and post-medical expenses, etc. Moreover, individual health insurance offers flexibility and control, allowing you to customise the cover to suit your exact requirements.
   
• Family Floater Health Insurance
  In a family floater health insurance, your family can be covered under the same policy, and all the members can share the sum insured. The premiums may be lower too. Furthermore, with a Family Floater Health Insurance plan, you can enjoy the convenience of paying only one premium for the entire family, instead of multiple premiums for individual policies.
   
• Senior Citizen Health Insurance
  Senior citizen health insurance is specifically created for senior citizens who are usually above the age of 60. They have a higher risk of getting sick, due to their age and the weakening of their immune systems. Therefore, the premium for this policy is higher to cover any potential medical costs that may arise. This policy covers medical expenses, including pre- and post-hospitalisation, accident-related damages, domiciliary hospitalisation, psychiatric treatments, etc.
  Health
   
• Group Insurance
  Group health insurance plans are provided by large organisations or firms to their employees. They offer financial protection against accidents, illnesses, critical illnesses, psychiatric illness, maternity costs, etc. Additionally, the premiums are lower because the risk is spread out over a large group, making the plans more affordable. It is important to bear in mind, however, that once the member leaves the group/organisation, their health insurance coverage is no longer valid.
   
• Maternity Health Insurance
  Maternity Cover provides a financial safety net for parents planning to have a baby, by covering the costs of delivery, pre and postnatal care, infertility treatments, etc. and ensuring that the family can focus on the joys of parenthood. Expenses related to the newborn baby may also be covered up to the first 90 days. The cover has a waiting period of 9 months to 4 years (this may vary across insurers).
   
• Top-Up & Super Top-Up Health Insurance
  Top-Up and Super Top-Up health insurance plans provide additional coverage on top of your existing health insurance policy. They help to bridge the gap between your existing health insurance coverage and any additional medical expenses you may incur.
  These plans come with a 'deductible’. A deductible is a predefined amount you need to pay from your pocket before the health insurance company starts paying for medical expenses. This clause acts as a safety measure for insurance companies to ensure that people don't make frivolous claims.
   

Benefits of Comparing Health Insurance Plans Online

• It’s Simple And Hassle-Free
  It is easy to compare all available policies and their benefits online. It helps you make an educated decision without having to consult agents or providers. Furthermore, the online platforms are available 24/7, allowing you to make decisions at your own pace.
   
• It’s Cost-Effective
  Insurance platforms may offer discounts if you purchase health insurance online. This makes it an economical choice, as it is possible to obtain quality coverage at an affordable cost.
   
• It Helps You With Premium Calculations
  Online premium calculators provide you with an estimate of the premium you will have to pay for a particular policy. This helps you to compare the different policies available and make an informed decision about which one is most suitable for your needs. Additionally, it allows you to adjust the amount of coverage and other parameters to find a plan that is within your budget.
   
• You Can Customise Your Plan With Various Add-Ons
  There are several add-ons available with health insurance plans, like -
  Accidental Disability Rider: Provides financial protection if you become disabled as a result of an accident. In the event of complete disability, the total sum assured will be paid. However, if you’re partially disabled, a portion of your sum assured is provided based on the severity of the condition. Please note that the conditions related to the payout will vary across insurers.
  Room Rent Waiver: Room rent is the per-day bed or room charges that you are required to pay when you get admitted to a hospital. A room rent limit is a limit up to which your health insurance will cover the per-day hospital room charges. Some policies come with a room rent limit. If you want to avoid the limit, you can opt for a room rent waiver add-on. It will increase or waive the room rent limit laid down by your health insurance plan.
  Maternity Cover Rider: This add-on covers expenses associated with pregnancy like delivery expenses, medical bills, and other related costs. It may also cover a newborn baby for a certain period of time or cover vaccination of the baby. The conditions vary across policies. Please note that the coverage can be availed only after the waiting period is over.
  Critical Illness Rider: If you are diagnosed with any of the critical diseases listed under the policy, you will receive a sum of money.
  Hospital Cash Rider: If you opt for this rider, you will receive a cash amount every day you are admitted to the hospital. To qualify for coverage, you need to be hospitalised for at least 24 hours.
  This is an indicative list of riders. There may be more, depending on the health insurance policy you choose.
   
• Comparing Policies Is Free Of Charge
  Many insurance platforms offer free quotes online so that people can compare policies and prices easily.
   
• You Can Pick The Optimal Level Of Coverage
  Online health insurance calculators provide an easy-to-understand visual comparison of plans and their coverages, allowing you to compare deductibles, co-pays, out-of-pocket limits, and other features. This helps you choose a plan that best meets your needs in terms of coverage and cost.
   

Checklist For Buying A Health Insurance Policy

When acquiring the health insurance policy, it's crucial to keep the below essential things in mind –

• Planning for Future Healthcare Costs
  In today’s rapidly evolving healthcare landscape, it is essential to consider the impact of inflation on medical expenses. The sum insured that seems sufficient right now might fall short in the future. As you grow old, certain factors like age and health conditions can limit your ability to upgrade coverage. So, it is wise to buy health insurance coverage that is adequate to support you in your later years.

• Room Rent Limitations
  Many health insurance plans, particularly those with a sum insured below Rs. 5 lakhs, come with room rent limits. These restrictions extend beyond just the room's cost, impacting the entire hospital bill. If the chosen room exceeds the eligible rent, the insurer will deduct the excess room charge and proportionately deduct all other associated medical expenses. So, despite having sufficient health insurance coverage, you may end up with significant out-of-pocket expenses due to room rent limits. Hence, as far as possible, always opt for a policy with no or low room rent limits.

• Specific Treatment Limits
  Some insurance companies may impose limits on certain diseases or treatments within your health insurance policy. These limits, often found in the policy's fine print, could lead to substantial out-of-pocket expenses even if you have adequate coverage.

For example, Elsa purchases a health insurance policy with a sum insured of Rs 20 lakhs that comes with a limit of Rs. 1 lakh for cataract surgery. A few months later, she requires a cataract surgery costing around Rs. 2 lakhs. In this case, the insurer will only cover Rs. 1 lakh, leaving Elsa with the rest Rs. 1 lakh to pay personally from her end. This is why you should review the terms and conditions of the policy and compare fine print details across different plans before finalising your choice.

• Copayment Clauses
  A copayment clause in your health insurance policy can significantly impact your claim. If your plan includes a co-payment clause, you will be required to contribute a portion of the approved claim before the insurer steps in to cover your medical expenses.

For example, Gaurav opts for a plan with a 10% copay clause and incurs a total hospital bill of Rs. 3 lakhs for his father's treatment. Let’s assume that after deducting the cost of non-medical items, the insurer approves a claim of Rs. 2.5 lakhs. In this case, he will need to pay Rs. 25,000 upfront. The insurer will then cover the remaining amount i.e., Rs. 2,25,000.

Hence, look for a policy without a copayment clause. If that’s not possible, you should opt for the lowest copay to minimise out-of-pocket expenses.

• All-Inclusive Day Care Coverage
  Certain medical procedures or surgeries such as chemotherapy, radiotherapy, eye surgery, colonoscopy, etc. that used to necessitate extended hospital stay in the past can now be done within 24 hours, thanks to medical advancements. These are known as day care treatments. While insurance companies provide you with a list of covered day care treatments, it is important to note that this number can be deceptive.

For instance, one insurer might categorise "eye surgeries" broadly, while another may break it down into distinct procedures like cataract surgery, corneal incision, tear duct operations, etc. The insurer might engage in this practice with the aim of increasing the range of covered treatments. To avoid confusion and ensure future additions are covered, choose a health insurance policy that encompasses all day care procedures.

• Coverage For Organ Donor Expenses
  The expenses associated with organ transplants, such as kidney, liver, heart, etc. can be exorbitant. Beyond the actual transplantation, which involves harvesting and screening the organ, there are two surgeries required – one for the organ receiver and another for the organ donor.

While a health insurance policy typically covers the hospitalisation expenses for the organ receiver, it excludes costs incurred by the organ donor such as organ screening costs, pre-hospitalisation tests, surgery expenses, post-hospitalisation recovery costs, expenses associated with complications after surgery, etc. To minimise potential out-of-pocket expenses, you should consider opting for health insurance with an organ donor cover. This additional coverage ensures that both the organ receiver and donor expenses are taken care of, providing a comprehensive solution.

• Secure Your Coverage With Restore / Refill Benefit
  In the current era of soaring medical expenses, there is a possibility of depleting your entire insurance coverage in a single major hospitalisation. This may leave you without health insurance protection for the rest of the policy year. In case of a family floater plan, other family members may be left without sufficient protection for the rest of the year.

To address this concern, health insurance plans offer a valuable feature known as restoration benefit. This feature steps in to replenish or restore your sum insured once it is used up within a policy year. Some policies come with this feature by default, while in others, it is available as an optional benefit.

The restoration benefit kicks in when your sum insured is exhausted, ensuring you and your family members (in the case of a floater plan) are not left vulnerable without coverage. It is, however, important to note that the terms governing the restoration of the sum insured can vary among insurers and products. Therefore, you should understand the specifics of how and when restoration is triggered, as well as its extent, before making any decision.

Here are some key aspects to consider when you opt for the restoration benefit –

1. Built-In Feature vs. Add-On
   Opt for a plan where restoration is an inbuilt feature, not an additional add-on. This way, you will not incur extra charges for an 'add-on cover.'
    
2. Unlimited Restoration
   Choose a plan that offers unlimited restoration, allowing your cover amount to be replenished any number of times within a policy year.
    
3. Condition-Specific Triggers
   You should be aware that in some plans, restoration is activated only for unrelated conditions. For instance, if you use your base sum insured for liver surgery, it will be restored but cannot be used for the same surgery again. You can prevent this situation by investing in a plan that offers restoration benefits for both related and unrelated conditions.
    
4. Trigger Points for Restoration
   Different plans have distinct conditions specifying when the restoration feature gets activated. Some activate only when the entire sum insured is exhausted, while others trigger even with partial exhaustion. To ensure comprehensive coverage for each hospitalisation, consider a plan that restores the sum insured even after partial utilisation.
    
5. Refill Limits
   The restoration feature in some policies refills up to the base policy cover, while others refill only up to the amount claimed by you. You should choose a policy where restoration extends to your base cover, providing a more substantial coverage for every hospitalisation.

• Inclusion of Non-Medical Expenses
  Health insurance plans generally do not cover non-medical expenses which include the cost of consumables like gloves, nebulization kits, oxygen masks, etc. However, by choosing a health insurance policy with a consumable cover, you can ensure coverage for these non-medical expenses.
   

What are the Factors That Affect Health Insurance Premiums?

• Sum Insured
  Your health insurance premium is affected by the amount of coverage you choose. The sum insured is the maximum amount of money you can claim from the insurance company for medical expenses. Keep in mind that if you have an inadequate sum insured, your hospital bill may go beyond it and you will have to pay the difference yourself. It is therefore important to choose your sum insured carefully, so you don't end up with major out-of-pocket expenses.
   
• Type Of Policy
  Depending on the health plan you choose, your health insurance premium will vary. For instance, in some cases, individual health policies for each family member may cost you quite a bit compared to family floaters.
   
• Pre-Existing Diseases
  A pre-existing disease refers to any condition, ailment, injury, or disease diagnosed or treated by a doctor within 48 months prior to the date of issue of your health insurance policy. If you suffer from a pre-existing medical condition, such as diabetes, high blood pressure, or asthma, you will likely incur large, recurring hospital expenses. Their premiums will be higher than the premiums of healthy people of the same age group.
   
• Medical History
  Your and your family’s medical history will also have an impact on the premium amount. If you have a medical history or if your immediate family members (like your parents or grandparents) have shown a history of cancer, heart disease, diabetes, etc., you are more likely to develop these diseases - placing you at a higher risk. Consequently, your premium will rise. This means that it's important to be aware of your and your family's health history, as it could have a direct effect on your own health and the cost of your health insurance.
   
• Lifestyle Habits
  Your premium may also be affected by lifestyle habits such as smoking, chewing tobacco, or snuffing. These lifestyle habits are considered to be factors that increase an individual's risk of illness, and may thus, result in higher premiums. This is because risk of lung infections, cancer, and other critical illnesses is high for smokers, posing a huge risk for insurers.
   
• Add-Ons
  Add-ons are additional benefits you can add to your base health insurance policy to enhance your coverage. For example, maternity benefit cover, critical illness cover, room rent waiver, etc. Keep in mind that you will need to pay an extra premium for these covers.
   
• Co-payment
  A copayment is basically a percentage of the claim amount that you will have to pay from your end. Your insurer pays the rest. Say your policy includes a 15% copay clause. If you make a claim, you'll need to pay 15% of the claim amount from your end and the insurer pays you 85% of the claim amount.
  Some health insurance policies may include mandatory co-payment clauses, while others may allow you to choose your co-payment amount. A higher co-pay will lower your total premium. But, you will need to pay a larger amount during claims. Conversely, having a lower co-pay will result in a slightly higher premium, but you will pay less during claims. Make sure you read your policy wording to know the copay percentage applicable in your policy.
   
• Job
  Your insurance premium will also be affected by the level of risk you face at work. Individuals who are exposed to higher levels of risk might have to pay higher premiums. For instance, a person who works in a school as a teacher will pay less than someone working as a fireman or in a factory where injuries are more common.
   

 How to Reduce Your Health Insurance Premiums?

You can save on your health insurance premiums if you follow these tips –

• Smart Cost Sharing
  You should choose health insurance plans that let you voluntarily opt for deductibles and co-pays. A deductible is a certain amount you need to pay from your own pocket before the insurer pays for the rest, and co-payment is a certain portion of the approved claim that you must pay from your end before the insurer steps in to cover the medical expenses. By assessing the amount of money you can readily pay, you can effectively reduce your health insurance premium.
   
• Avoid Unnecessary Riders
  If you wish to add riders to boost your policy coverage, be mindful not to overdo it. The more riders you add, the higher your premium. Only include the add-ons that feel relevant to avoid unnecessary expenses.
   
• Lock in Long-Term Savings (Multi-Year Discount/ Long Term Discount)
  As discussed earlier, health insurance policy offers you the flexibility to customise it to fit your needs perfectly. One option is to select the desired policy term, with choices ranging from 1 to 3 policy years. Multi-year policies with a policy duration 2 or 3 years offer you attractive discounts. And opting for such a plan not only saves you on the premium amount but also shields you from yearly renewals.
   
• Save More With Family Floater
  Enrolling yourself and your loved ones in a family floater policy not only benefits you but also insurers, as they acquire multiple customers at once. To encourage individuals to choose this umbrella policy, many plans provide appealing discounts, ultimately reducing premiums.
   
• Know Your Room Rent Limit
  The maximum amount your health insurance policy covers for your hospital room is the room rent limit. If you choose an expensive room over the specific limit, then you will need to cover a proportionate share of the total bill, and not just the extra room cost. Some plans have add-ons to lower your room limit or set sub-limits on the room when you get hospitalised. Opting for these add-ons can be a cost-effective choice if you don't prioritise luxurious hospital rooms.
   
• Take Part In Wellness Programs
  Certain insurers offer wellness programs to promote awareness about a healthy lifestyle. Engaging in such a program can help you get discounts or benefits when renewing your policy. You should remember that these discounts apply only during renewal, and you must meet all terms and conditions to qualify for them.
   

Common Health Insurance Terms

Listed below are some of the key health insurance terms that you need to  be aware of -

1. Exclusions
   Certain health conditions or illnesses will not be covered by your health insurance policy at any cost. These are called exclusions. It is crucial to review this list before choosing your plan.
    
2. Free Look Period
   The free-look period is a specific time frame during which you can check your policy's terms and conditions. It begins from the date you receive the policy document and lasts for 15 days. If no claims are made during this period, you will receive a premium refund. However, some charges may be deducted like stamp duty charges, administration charges, etc.
    
3. Grace Period
   This is the specific timeframe after the premium due date during which you can still make a payment to renew or continue your policy without losing benefits like waiting periods, coverage for pre-existing diseases, etc. No coverage is provided during the period of non-payment.
    
4. Medically Necessary Hospitalisation
   Your insurance kicks in for inpatient expenses only if the hospitalisation or treatment is deemed medically necessary. Here, ‘medically necessary’ means that –
   • The treatment or hospitalisation is needed to manage the illness or injury you're facing.
   • The treatment should not go beyond what is required to provide safe, adequate, and fitting medical care in terms of scope, duration, or intensity.
   • The treatment or hospital stay must be suggested by a medical professional who is not related to you.
   • The treatment should align with the widely accepted professional standards in international medical practice or as recognized by the medical community in India.
      
5. Network Provider
   A network provider is a hospital that has been approved by an insurer, TPA, or both, to offer medical services to you, without the need for any upfront payments.
    
6. No Claim Bonus (NCB)
   No Claim Bonus is a benefit or discount offered by the insurance company for not making any claims during a policy year. It is given on policy renewal either by increasing the sum insured or decreasing the premium amount.
    
7. Portability
   Portability is a process of transferring your current health insurance policy to another plan offered by a different insurance company. If you are considering porting your health insurance policy, make sure to inform your current insurer 45 days before your policy is up for renewal.
    
8. Pre-Existing Diseases (PED)
   A pre-existing disease refers to any ailment, injury, or disease diagnosed by a doctor or medical conditions for which medical advice or treatment was recommended within 48 months before the policy's issuance.
    
9. Waiting Period
   When you get a health insurance policy, you cannot claim for all diseases right away. Some conditions will not be covered for a certain period of time. This timeframe is called the 'waiting period.' After the waiting period passes, these temporary exclusions are lifted, and you can claim for all eligible conditions.
    
10. Reasonable And Customary Charges
    Reasonable and customary charges refer to the fees for services or supplies that are the usual charges for a specific provider and are in line with prevailing charges in the geographical area for similar services.
     

Things to Evaluate While Renewing Your Health Insurance

• Add Or Remove Family Members
  During renewal, if you and your family are covered under a floater, you have the opportunity to add or remove family members and also modify the coverage to accommodate all their medical needs. For instance, you can add your spouse to your health plan if you have recently been married or if you have a newborn baby in the family, you can add them to your policy. Or you also have the option to remove a family member in the event of their death.
   
• Enhance Your Sum Insured
  Rising medical inflation, advanced healthcare treatments, growing population, increased pollution are a few things that have led to soaring healthcare costs. To ensure that your health insurance is sufficient and to protect you and your family in the long run, it is important to analyse if the coverage you have is enough, and whether upgrading it is necessary. And, renewing your health insurance is a good time to upgrade it. Make sure that you and your family have enough health insurance coverage for a minimum of 20-30 years while taking inflation into account.
   
• Keep Track Of Changes In T&Cs
  Insurers are allowed to modify policy terms and conditions after taking prior approval from the Insurance Regulatory and Development Authority of India (IRDAI). So, before renewing your policy, check with your financial advisor to see if there have been any changes. As per the IRDAI portability guidelines, you have the option to migrate or port your existing health insurance policy if you are not satisfied with the revised terms.
   
• The Option Of Portability Is Available
  You can port your policy if you are unhappy with the services provided by your insurance company or its features and benefits no longer appeal to you. With health insurance portability, you can switch providers while keeping your accrued benefits intact. If you wish to port your policy, you should notify your insurer 45 days prior to the renewal date.
   
• Add Relevant Riders
  You can add riders to your basic health insurance plan to widen your base coverage. Health insurance offers riders like the critical illness rider, maternity rider, room rent waiver, etc. When renewing a policy, you can choose riders according to your needs. For example, if you have an accidental death benefit rider, the insurer will pay the rider payout to your family - if you pass away due to an accident.