How good is Arogya Sanjeevani as a health insurance cover?

All about the Arogya Sanjeevani Policy and whom it can benefit – plus features, exclusions, limitations, costs, and suitability.

How good is Arogya Sanjeevani as a health insurance cover?

Arogya Sanjeevani is a standard health insurance policy that was introduced by the Insurance Regulatory and Development Authority of India (IRDAI) on 1 April 2020. IRDAI has accordingly instructed all general and health insurance companies to introduce this policy. As an insurance product, it can be adopted and included by all insurers, maintaining uniformity in its coverage and the terms and conditions. This policy is available for individuals as well as families, and its coverage ranges from Rs 1 lakh to Rs 5 lakh. The premium and customer service may differ from one insurer to another. In its press release, the IRDAI has mentioned that hospitalisation treatment costs of COVID-19 will also be covered under the Arogya Sanjeevani health insurance scheme.

An important aspect of Arogya Sanjeevani health insurance scmeme is that its features will remain uniform across all insurance companies. This includes the terms of coverage, inclusions and exclusions, and other terms and conditions. Zone pricing cannot be made applicable to this product. In other words, the premium amount will remain the same everywhere, irrespective of the residential location of the insured. The health insurance premium will, however, vary from insurer to insurer. This is because the cost of the plan differs among these companies. The claim ratio, manpower cost, management expenses, and presence or absence in various locations affects the premium. 

To address customer risk and uncertainty, the policy will have a 5% co-pay inclusion. Accordingly, the customer will bear 5% of the sum insured while the remaining will be borne by the insurer. Arogya Sanjeevani health insurance scheme is an indemnity-based plan and has a waiting period of 30 days.

Features of Arogya Sanjeevani health insurance scheme

Let’s look at some important features of the Arogya Sanjeevani health insurance scheme.

  • The insured can be between the ages of 18 and 65.
  • Children of the insured can be between the ages of 3 and 25.
  • A renewal grace period of 30 days is offered.
  • It can be renewed for the lifetime of the policyholder.
  • Pre-hospitalisation expenses of 30 days and post-hospitalisation expenses up to 60 days are accepted.

Related: Insurers to offer standard health policy ‘Arogya Sanjeevani’: IRDAI

Coverage

Arogya Sanjeevani covers hospitalisation as well as pre- and post-hospitalisation expenses. This includes room rent, boarding expenses, nursing expenses, fees of doctors, surgeons, anaesthetists, medical practitioners, consultants and specialists, charges of ICU, operation theatre and ambulance. It will also cover daycare expenses, boarding expenses, and medicine costs during the hospital stay. Treatment expenses under Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy are also covered under the Arogya Sanjeevani health insurance scheme. Procedures like robotic surgery, stem cell-based treatment, oral chemotherapy, balloon sinuplasty, intravitreal injections are also among the modern treatments covered. Cataract treatment is allowed, subject to specified maximum limits. Dental and plastic surgery, when conducted as a treatment for injuries and diseases, are also covered. 

Exclusions under Arogya Sanjeevani health insurance scheme

Out-patient department (OPD) expenses are not covered under Arogya Sanjeevani, nor are diagnostic and investigative tests. Maternity hospitalisation expenses and optional plastic and dental surgeries are not covered either. Other constructive procedures like obesity and weight control, infertility and sterility treatments or gender change operations are not covered. Treatment and rehabilitation costs for alcohol and drug de-addiction are not covered. Any medical expenses resulting from participation in dangerous sporting events and adventures are also not accepted under the Arogya Sanjeevani policy.

Restrictions under Arogya Sanjeevani health insurance scheme

The room rent sub-limit is 2% of the sum assured up to a maximum of Rs 5000. For ICU, the sub-limit is 5% up to a maximum of Rs 10,000. In the case of modern medical procedures, the insured can claim up to 50% of the sum assured. Cataract operations are covered up to 25% or Rs 40,000, whichever is lower, per eye. Besides, the sum assured of an Arogya Sanjeevani policy cannot be more than Rs 5 lakh, unlike other policies that can be increased by paying a higher premium.

Riders in insurance may be quite common but deductibles, riders, and variants are not allowed against this policy. In case you don’t know what insurance riders are, these are additional benefits or amendments that the insured can make to their policy.

Related: Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana: What you need to know

Premium

As mentioned above, the premium amount will vary from insurer to insurer. If you are a 35-year-old male looking to get a cover of Rs 5 lakh, you are likely to be offered premiums ranging upwards of Rs 3000 and up to Rs 7500. You can add your spouse and two children and go for a family floater plan. The premium for this could be between Rs 7000 and Rs 15,000. For a better idea of the premium cost, you could check a health insurance premium calculator. Further, parents and parents-in-law can also be included in the family floater plan at a reasonable additional premium. The premium can be paid monthly, quarterly, half-yearly, or annually. Note that health insurance tax benefits are available under the old income tax regime.

How Arogya Sanjeevani health insurance scheme differs from other health plans

A major difference between Arogya Sanjeevani and other health insurance policies is that the sum assured can be increased in the latter. Another important difference is the absence of riders under Arogya Sanjeevani. At the same time, the premium in other policies can be quite high, generally 20–50% higher. This can further increase on selecting add-ons. The room rent cap in other plans often doesn’t have a money limit, unlike Arogya Sanjeevani. Basic health plans contain a 10–30% co-payment by the insured, whereas in Arogya Sanjeevani it is 5%. Unlike Arogya Sanjeevani, other health plans can have different premium rates for different geographical locations within the country. Regular plans also offer higher no-claim bonuses, which can be up to 100% of the premium amount. In the case of Arogya Sanjeevani, it can range between 5% and 50%. 

Related: Budget 2020: What are the new schemes you need to know about?

Arogya Sanjeevani is widely regarded as part of the government’s aim to extend health insurance to the masses. Going by its features, it is quite apparent that the product is positioned as an entry-level health cover, with its low premium and the cap on sum assured. As further encouragement for entry-level buyers, the co-payment option is kept at 5%, much lower than is usual with conventional health insurance plans. Therefore, it is an ideal insurance product for a first-time health insurance buyer. 

IRDAI has ensured that the basic features of this policy remain uniform across all insurance providers. This encourages buyers as there’s less clutter when it comes to understanding the terms and conditions of the policy. The only considerations left for the buyer to decide would be the premium amount and the quality of service accepted from the insurer.

With its low sum assured cap, Arogya Sanjeevani may not be suitable for people living in areas with higher medical cost, such as metro cities, but is sufficient for other places in the country. If you wish to avail of a higher sum assured, you can combine it with a super top-up plan. The super top-up plan comes into force once the deductible limit of the base plan is surpassed. On the other hand, young and first-time insurance buyers should find the Arogya Sanjeevani health insurance scheme suitable to meet their health insurance needs. Here is list of government’s social welfare and health schemes – read this to find out if you are eligible?

Here are some frequently asked questions you might have about Arogra Sanjeevani health insurance scheme

1. Does the Arogya Sanjeevani health insurance scheme offer cashless treatment in network hospitals? 

Insurers provide cashless hospitalisation in network hospitals to policyholders of the Arogya Sanjeevani health insurance scheme.

2. Can Arogya Sanjeevani health insurance scheme be ported to another insurer after a few years if the customer is not happy with the service provided by the insurer?

Yes, it can be ported from one insurer to another insurer as per the interest of the policyholder.

3. Is there a cap on the number of claims in a year under the Arogya Sanjeevani health insurance scheme?

No, there is no cap on the number of claims. 

4. Does Arogya Sanjeeveni health insurance scheme cover AYUSH benefits?

Yes, treatment carried under AYUSH is eligible for policy cover. AYUSH benefits comprise of hospitalisation expenses if you have obtained alternative treatments such as Ayurveda, homoeopathy, Siddha, etc, at an approved hospital.