By Sunil Dhawan
Of late, more and more people have started leading a healthy lifestyle, backing it up with wellness programmes. This certainly helps but does not remove the risk of being hospitalised due to unforeseen events. The need for adequate health cover is increasingly becoming critical and consequently choosing the right health insurance plan has become very important. Let's look at few important features that could help you take a more informed decision.
Lifetime Renewability: As per IRDAI regulations, insurers are mandatorily required to offer health insurance for an entry age of up to 65 years. Most private insurers however, do not have such age-limits in their health plans while most state-owned general insurers cap the entry age at 65. As per rules all policies have to offer lifetime renewability. Naval Goel, Founder & CEO, PolicyX.com, says, "If you fail to renew the plan, then at the time of making the claim (in any new policy), you will also lose the existing benefits of the lapsed policy." Once the policy is issued, the policyholder has the right to continue renewing it lifelong. Lifetime renewability would be available even if there is a claim made in the previous year. Insurer cannot deny renewal on arbitrary grounds and has to furnish cogent reasons in writing if it does so.
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Pre-existing ailments: All health insurance plans cover pre-existing ailments but after a period of 48 months. Some plans cover pre-existing ailments even after 36 months or waiting periods lesser than this. However, this coverage of pre-existing diseases is conditional upon the buyer honestly making all medical disclosures at the time of buying the policy. This means that in case a person actually suffers from a disease at the time of buying the policy but is unaware of the fact and therefore declares himself as medically fit then the insurance company would honour the pre-existing disease related claim after 48 months / the predefined waiting period.
However, in case the insurer suspects that the buyer was aware of the pre-existing disease at the time of buying the policy then the company may refuse to honour the claim. This is the reason why it is important to disclose any pre-existing ailment at the time of buying for a smooth claims settlement process later on. Further, coverage of certain defined and specific ailments have a 'waiting period' of 12 or 24 months, post which they are covered for claim. Swami Saran Sharma, CEO, insuringindia.com says, "Since most individual insurance policies do have a pre-existing diseases exclusion clause ranging from two to four years, one should be very cautious while changing the insurers. Every time you change the insurer, pre-existing period condition will start from zero unless the policy is properly ported to the new insurer by giving a due notice to the existing insurer."
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Sub-limit: In today's times, sub-limits in health insurance plans have become an important feature to keep an eye on. The total medical cost during a hospitalisation would typically include doctor's fees, room-rent, surgery fees, operation charges and cost of medicine amongst various such other cost-heads. Sub-limit refers to limiting re-imbursement under each or some of such cost-heads to a pre-defined level. For example, reimbursement of room-rent may be capped at 1 per cent of the sum insured. So, irrespective of the total sum insured under the policy, one may have to pay some portion of the hospital bills unless one sticks to the limit. Some health plans do not have any such sub-limits while few others offer an option to reduce premium payable by including sub-limits at the time of buying the plan.
Day-care and OPD expenses: Normally, the most important requirement for a health insurance claim is the minimum hospitalisation of 24 hours. However, with technological advancements, certain surgeries and procedures require less time. Therefore, many health insurance plans have started covering claims for day-care expenses such as dialysis, chemotherapy, eye surgery and lithotripsy, among others. Generally, up to 140 such surgeries are covered by most insurers, with or without any restrictions. Certain hospital procedures, such as dental care, neither fall under day-care and nor do they require 24-hour hospitalisation. They are referred to as out-patient procedures and few plans have started offering claim on out-patient expenses as well but with restrictions.
Naval informs, "The basic difference between OPD and day care expenses are the types of procedures that they cover. OPD includes small time medical expenses like dental treatment etc while day care treatments involve larger expenses like a catarct surgery or radiation therapy which may include hospitalization for less than 24 hours."
No medical tests upto age 45: Insurers, before issuing policies, evaluate the policy applicant's health as per disclosures made in the application form and also through certain medical tests. Most insurers do not require policy buyers below 45 years of age to undergo medical tests unless the buyer has an adverse medical history. The buyer should, however, make all required medical disclosures including existing medical treatment or any taken in the past. For easier claim settlement, one may voluntarily undergo a medical check-up/test and submit the reports to the insurer.
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Conclusion: While choosing a health cover, one should ideally start by comparing plans from 2-3 preferred insurers. Take a close look at the inclusions and exclusions in the most basic plan being offered by them. Do not base your decision solely on the premium, instead look for simple plans with less conditions and restrictions in them. Also remember, every member of the family needs health insurance cover to tide over any unforeseen medical exigencies in future.
Source: Economic Times
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