Health Insurance: Benefits, Types, Coverage, Mediclaim settlement, Floater - All your questions Answered

If you’re concerned about getting health insurance, it’s imperative to do your research. In this article, we tell you everything you must know when it comes to health insurance.

How to avoid health uncertainties: Reasons to get Health Insurance

Neglected lifestyle, hectic schedules, rising stress levels in life - all point towards a medically precarious life. Health issues are inevitable. And these issues, unfortunately, don’t come with a warning. To make sure that you can put your health and  of your loved ones at the forefront, opting for health insurance is a must. It protects you from the financial setback of hospital bills, which encourages you to choose the best medical options for treatments. 

Here are a few important questions that you may have in mind while selecting a health insurance policy.

What is health insurance?

Health insurance is pre-emptive insurance that covers the risk of a person incurring medical and/or surgical expenses on account of sickness or injury.

Why is health insurance important?

The rising cost of medical facilities, especially in case of complex medical procedures and life-threatening situations, makes it difficult for the average Indian to bear the burden of quality healthcare. Health insurance can provide this at a nominal cost.

Related: Why Insuring Your Health Is A Smart Decision?

What kinds of health insurance plans are available?

There are categories of health insurance at a broader level:  (a) Indemnity plan, which includes mediclaim plans, top-ups and super top-ups; and (b) Defined benefit plan, which includes critical illness coverage and daily hospital cash plans. 

However, while purchasing a health plan, you will have the option to buy Individual Health Insurance, Family Floater, Group Health Plans, Senior Citizens Plans, Maternity Plans, and Critical Health Insurance. You can also buy Top-up Insurance for coverage of a higher amount.

What tax benefits do I get if I opt for health insurance?

Under Section 80D of the IT Act, you can claim up to Rs 25,000 for yourself, your spouse and dependent children. Rs 25,000 for dependent parents is available as a deduction from taxable income on the premium paid. If the parents are over the age of 60, the deduction available is Rs 50,000. If both taxpayer and parents are above 60, the total deduction is Rs 1 lakh.

What are the factors that affect health insurance premiums?

Several factors affect your health insurance premium, prominent among them being age, gender, marital status, body mass index (BMI), pre-existing conditions, family medical history, consumption of injurious substances, profession, location, and previous insurance (if any).

What does a health insurance policy not cover?

You can refer to the list of exclusions in your policy document for the treatments and ailments that are not covered. Most health insurance policies do not cover the eye and dental care, cosmetic surgeries, lifestyle-induced diseases such as tobacco, alcohol, and drug abuse, sexually transmitted diseases, intentional self-injury or suicide attempt, injury from adventure sports, non-allopathic treatment, and injuries arising due to act of war.

What is the procedure for change of address for medical insurance?

A change of address does not affect the insurance premium and is considered a non-financial endorsement. The address can be easily changed on the service providers’ web portal or by dialling the insurer’s toll-free number.

What should one look for while choosing a health insurance plan?

Some of the primary factors you should consider in a health insurance plan: affordability and competitiveness of insurance premium and cover, easy and swift claim process, shorter waiting period, a large network of hospitals, option to add top-ups and riders, option for a family healthcare plan, pre-and post-hospitalisation benefits, cumulative bonus, lifetime renewals, and free medical checkups. In recent times, the extent of COVID-19 treatment coverage is also worth considering.

I already have health insurance and want to increase the sum insured; what should I do?

You can opt for a top-up on your insurance plan. This will increase the insurance threshold of your policy at affordable premium rates.

Is maternity care covered by health insurance policies?

Most insurance companies either do not cover maternity care under a standard insurance policy or put a limit on the claim that can be made. However, you may be able to add a maternity insurance rider to your main health insurance policy.

I am looking for a single health insurance policy that can cover my parents or in-laws too. What should I buy?

Some insurance providers offer the option to add parents to your ‘family floater’ policy for no additional cost. Parents and in-laws can be added to the comprehensive family policy by paying an additional cost to the premium.

Related: Things To Consider While Buying Health Insurance For Your Parents

What is meant by the ‘family floater’ policy?

A family floater policy is a single policy that covers the medical expenses of all the members of a family included in the policy.

Can I cancel my policy and, if yes, will I get my premium back?

Yes, you can cancel your insurance policy. Within the free ‘look-in’ period, your premium will be refunded after deducting stamp duty and proportionate risk charges. If a medical test was done, that cost will be deducted too. After the free look-in period, the company may refund the premium, or a part thereof, based on its policy specifications.

What is covered under the hospitalisation benefit?

There are different types of hospitalisation benefits. Cash benefit allows for cash reimbursement for each day spent in the hospital, while pre-and post-hospitalisation benefits reimburse for the costs of care before and after hospitalisation respectively. In the case of cashless hospitalisation, the insured does not have to pay out of pocket.

How does one get reimbursements in case of treatment in non-network hospitals?

In such cases, you would need to fill and sign a claim form, produce the discharge certificate from the hospital, along with ailment history, bills, receipts, and memos from the hospital, plus diagnostic report, surgeon’s report, and certificate from the doctor stating the patient are cured. Also include details of previous policies (if any).

What is the procedure to get reimbursement in case of emergency hospitalisation?

The insurer has to be intimated within 24 hours of emergency hospitalisation. You must retain all bills and documents for the claim. The claim has to be filed between seven to fifteen days of discharge.

When will my claim be reimbursed?

Claims are reimbursed after all forms and documents as prescribed by the insurer are submitted by the policyholder. 

What is TPA?

Third-Party Administration (TPA) is the cashless service provided to a policyholder for all hospitalisation covered under the policy at any network or non-network hospital of their choice.

What are the facilities offered by a TPA?

Policyholders can avail of round-the-clock assistance from the TPA via a toll-free number, online assistance during hospitalisation, ambulance services, cashless hospitalisation, claims processing, and other services as defined by the insurer.

Related: 8 Health Insurance Jargons Explained

What is the maximum number of claims allowed in a year?

A policyholder can claim any number of times in a year as long as the value of the service provided remains within the insured limit.

What is a ‘health check’ facility?

Insurers may provide a free health checkup facility for customers every year or alternate year, depending on the policy terms.

Are diagnostic charges for X-ray, MRI, ultrasound etc. covered?

All diagnostic tests are covered under a health insurance plan as long as they are associated with the treatment or hospitalisation of the insured person.

I have an insurance cover provided by my employer for Rs 4 lakh covering my entire family. Can I take another family policy?

Yes, you can take as many additional policies as you wish. If you approach the same insurer, quoting your existing policy details can get you cheaper premiums.

How is a hospital defined under Mediclaim insurance?

As per the terms of insurance, a hospital needs to be registered as one with the local authorities. There are requirements like the number of beds, qualified practitioners and staff, equipment and record-keeping etc.

Is a medical checkup necessary before buying a health policy?

Usually, for customers below the age of 50 years, a medical checkup is not necessary. This may vary depending on the insurer and the plan.

How does one get reimbursement for pre-and post-hospitalisation expenses?

As a general practice, all original bills and documents on the case history from a period of 30 days before hospitalisation can be claimed as pre-hospitalisation. For calculating post-hospitalisation expenses, a percentage of the hospital bill (excluding room rent) or Rs 5000, whichever is lower, is settled on the doctor’s recommendation and discharge summary.

How does authorisation for planned hospitalisation work?

The hospital providing the care needs to send a pre-authorisation form duly signed by the customer to the insurance provider at least two days before hospitalisation. Any subsequent changes in the details provided may render the authorisation invalid.

Conclusion:

There are different types of health plans, designed to meet the needs of different types of policy buyers. You should always choose the health insurance that best fits your needs. While doing so, this article is expected to help you make an informed decision.

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