How many times do you need to visit a hospital to finally realise that you require a health cover? It just takes one medical emergency to make you understand how vulnerable you are when you have to foot the hospital bills. Whether you are rich or poor, young or old, being diagnosed of an illness that requires hospitalisation could be one hell of an ordeal. Diabetes, stroke, heart ailments, renal failure and similar other lifestyle diseases are increasingly becoming common these days. Medical science, thankfully, has improved in leaps and bounds and there are now super-speciality hospitals where many life-threatening diseases can be treated. But it all involves huge cost. The wealthy may be able to afford these expenses but what about the average middle-class people? Where do they get the money to meet the costs? For illnesses that call for surgery or hospitalisation, the medical expenses may easily run into six digit figures. Now imagine having to pay a huge amount within a few hours' notice. That surely can make you paranoid. This is exactly where a health insurance policy, commonly known as mediclaim in India, comes in to cover your expenses to a great extent and help you retain peace of mind.
At PolicyX.com, which is an IRDA approved website, you can freely compare and select the best plans to take care of your health needs and expenses in just a few minutes.
PolicyX.com helps you compare and save money on insurance. Health plans are one of the best ways to protect yourself and your family from rising medical costs. Buying health plans provide risk coverage against expenditures caused by any unforeseen medical emergencies. In current times of high medical inflation rates, failing to hold adequate amount of health insurance cover can prove to be a major personal finance disaster. This could lead to either poor health care because of non-affordability or spiral an individual into financial distress due to high medical bills. This is where the whole concept of medical policies comes into play. Best health insurance plans cover medical costs during hospitalization as well as pre and post stages of hospitalization.
The level of coverage mostly depends upon the type of the Medical insurance policy. A lot of companies now offer health insurance in India and therefore as a consumer, you have multiple choices from leading brands. To choose the best health insurance policy you should take advantage of our comparison services. Some of the brands offering health plans are MaxBupa, Bharti-AXA, Tata AIG, Apollo Munich, Star Health etc. PolicyX.com helps you compare and choose the best health insurance plan for you.
Following are three major types of mediclaim policies available in India.
This is the simplest type of all health insurance schemes and is called the individual healthcare policy. Such a scheme covers hospitalisation expenses for a person up to the sum assured. The yearly premium payable is usually directly proportional to the sum assured. For instance, if there are three members in your family, each of them can buy a standalone cover of Rs2 lakhs each. All the policies are independent of each other. If all three members require hospitalisation, all can get their hospitalisation expenses covered by up to Rs 2 lakhs.
Family Floater Policy
These are enhanced versions of the individual mediclaim policy. Here, the sum assured is floated among family members named in the policy. That is, it covers the medical expenses of the full family, up to your sum assured. The premium payable for a family floater policy is usually less than individual policies taken by each family member. Suppose, there are four members in your family; you can buy a family floater mediclaim for ?6 lakhs. Now anyone of the four insured can claim up to the full amount for expenses. But the cover will come down by the claimed amount for that policy year. So when a member of your family gets hospitalised and expenses in this regard is ?4.5 lakhs, the cover for the family floater policy would be reduced to ?1.5 lakhs. Upon renewal, the policy will again resume from ?6 lakhs. A family floater mediclaim policy makes sense because each member gets a big cover. Also the chance of more than one member getting hospitalised in the same year is quite low.
Unit linked Health Plan (ULHP)
Health insurance companies have recently introduced ULHPs that combine health insurance and investment, and return an amount once the term of insurance ends. The return, of course, depends upon the market conditions at that time. But these plans are still in the development stage and are recommended for those who can handle products like unit linked insurance plans (ULIPs) and unit linked pension plans (ULPPs).
It's advisable to stay away from ULHPs for several reasons.
Treat health insurance just as an expense. This is because unlike life insurance, you don't get back the premium you pay at the end of the term, if there’s no claim. Select an individual healthcare policy if you are single and a family floater if you have a family. You can get a tax exemption of up to Rs.15,000 under section 80D of the Income Tax (IT) Act, if the amount of premium is paid by credit/debit card or cheque.
The cost of mediclaim, as already said, depends upon the sum assured, the age of the insured, present health condition and previous medical history. A higher sum assured attracts a higher premium.
So what will be your ideal mediclaim requirement?
Well, there's no one-size-fits-all amount or a thumb rule here. Factors to consider in this regard includes a person's health condition, age, lifestyle, life stage, family illness history and of course affordability.
Remember that most mediclaim policies extend "additional benefits" like ambulance charges, daily allowance, and other expenses for hospitalisation. But most of these so-called benefits are superfluous. They usually increase the premium amount. Try to stay away from such mediclaim plans and stick to something simple.
Health Insurance by Employer
Several companies provide mediclaim for their staff. It also often covers hospitalisation expenses of the spouse, dependent children, and parents. It's advisable to take the mediclaim irrespective of the amount covered because you don't have to pay any premium for that. Now, whether you need to take another health insurance policy will depend on a few factors. Is the cover provided by your employer sufficient? Is the insurance company good enough? What will happen when you change jobs?
Mediclaim is provided as an incentive to employees. So it's important that you understand the insurance policy is details and also check the coverage. Ask your human resource (HR) department for the details; what's covered and what's not covered. In many cases, employees are satisfied over the fact that their company is providing health insurance, only to find out later that several things were not included at all or were covered only in parts.
Health Insurance For senior Citizens
Even about a decade back, mediclaim companies were unwilling to extend cover to the aged and senior citizens. But of late, several insurers are providing health insurance policies for them. Insurance cover paid to an individual aged 65 years or above can lead to an additional tax relief of up to Rs20,000. But remember that premium payable for senior citizens are much higher.
If you are employed and have a mediclaim cover from your employers, approach your HR manager and negotiate with the insurance company to provide an additional cover for your parents. The insurer may provide the cover at an attractive premium because the volume will be high.
Section 80D of the IT Act covers healthcare insurance. You can get up to ?15,000 off for premiums paid for yourself, spouse and dependent children; and up to ?15,000 for parents (?20,000 if the parents are aged above 60).
So, if you pay the medical insurance premiums of your parents, you can save up to Rs35,000 in taxes.
Third Party Administrators
A third party administrator, commonly known as TPA, is an organisation that processes claims and extends cashless facilities to the insured as a separate entity. TPAs, in effect, act as a middleman between the insurance company and the insured. A customer can deal directly with the TPA for settlement of claims and the organisation will help the insured with the process. TPAs are a specialised healthcare service provider and render a variety of services that include networking with hospitals and arranging for hospitalisation. The TPA concept was introduced by the Insurance Regulatory and Development Authority of India (IRDAI), to benefit both the insurer and the insured. While insurers benefit via reduction of their overheads and administrative costs, fake claims, and ultimately reducing claim ratios, the insured can take advantage of better and prompt healthcare service.
An insurer may have several TPAs. Similarly, a TPA can serve as an agent of multiple insurance companies.
Some of the key services rendered by a TPA are as follows.
Maintain a database of all policyholders
Issue identity cards to policyholders
Provide ambulance services
Give information to healthcare policyholders about networked and empanelled hospitals
Check with various investigations
Extend cashless mediclaim services
Process health insurance claims
Most people, though aware of how TPAs work, don't know how health insurance claims are settled. Once a mediclaim policy is sold, the TPA takes up the baton from insurance company. For claims settlement, the insured must approach the TPA for all verification and formalities.
TPAs settle claims in two ways.
You can avail cashless treatment facilities only in the networked hospitals of the insurance company. The TPA must be notified beforehand in case of a planned hospitalisation, or within a specified timeframe in case of an emergency. The hospital's insurance desk helps with all the paperwork. The TPA has to approve the mediclaim amount and the hospital will settle it with the insurer. There are likely to be exclusions i.e. expenses that the TPA won't pay. Such expenses must be settled by the patient party directly at the hospital cash counter.
The insurer can avail the reimbursement facility both at networked and non-networked hospitals. Here, you can avail treatment facilities and settle the bill directly with the hospital. You can then claim reimbursement of the expenses from the TPA by submitting the relevant bills and receipts.
A word of caution about TPAs
The TPA system of settling mediclaim has its own problems. All TPAs are incentivised by insurance companies to limit claims. Besides, they don't sell any health insurance policy. There have been several instances where the insured individual had to face a tough time for claiming hospital expenses.
Before buying a health insurance policy, check who your TPA is and how professional it is in claims processing. You can inquire about the TPA's track record with the IRDA. Even an online search can offer you a good insight on the insurance company and TPA. Some insurance companies don't appoint TPAs and settle claims directly. That is, they have their own in-house TPA.
If you have decided to buy health insurance online, then there are few documents that you need to provide such as:
Age proof - Any one of Birth Certificate, 10th or 12th mark sheet, Driving License, Passport, Voter ID, etc
Identity proof - Driving License, Passport, Voter ID, PAN Card, Aadhar Card, which proves ones citizenship
Address proof - Electricity Bill, Telephone Bill, Ration Card, Driving License, Passport, should clearly mention the permanent address.
Some plans require a medical check-up usually for elder people above the age of 45 years in order to make sure that the insured does not suffer from any chronic illness.
Passport Size Photo to have a record of the insured person`s identity for future references.
If you have decided to buy health insurance online, then there are few documents that you need to provide such as:
Very easy to buy, hassle free buying without going through heaps of paperwork
Takes less than 10 minutes to complete a purchase.
Simply enter basic requirements details as per the need and preference to find the best insurance plan for you.
Compare plans from various companies in less than 30 seconds and take a wise decision for your insurance investment.
Choose a plan which fulfills your criteria of insurance and be insured within minutes.
Complete online proposal form in 5 minutes, which asks you for your basic details for further reference.
Upload your documents and make payment towards the plan you want to opt for.
Bingo: You are now covered under the policy.
Those people who do not have much knowledge about health insurance often get confused between health insurance and mediclaim. Basically a mediclaim policy provides coverage for hospitalization expenses for a definite pre specified illness till a certain time as per the sum insured. Under mediclaim policy, the maximum limit for all claims is fixed at a definite amount. It works on the principle of indemnity in which hospitalization is a specific requirement to think about any claim. Even those people who are insured under a mediclaim policy need to pay hospitalization expenses from their pocket and the insurer will pay them later. Under a health insurance policy, policyholders will get the comprehensive coverage that will cover pre and post hospitalization as well.
The insured can also get coverage on ambulance charges, compensation for lost income, etc, but that all depends upon the riders associated with the health insurance policy. The upper limit of a health insurance policy can go to as far as Rs 60 lakhs. Normally, health care policies also offer discounts on a regular basis over a definite period of time. There is also a difference between health insurance policy and mediclaim on the basis of tax deduction. Health insurance premium paid towards a health insurance policy provides a tax exemption under section 80D of Income Tax Act, the funds paid towards mediclaim premium paid for self or spouse or children are appropriate for tax exemption of Rs 15,000 under section 80D.
Here are some of the important terms that you will come across while subscribing to a health insurance policy.
The sum assured, in simple terms, is the maximum coverage amount you can get in a policy year. It forms the basis of all your claims. Consider the increasing costs of hospitalisation, medicines, and treatment before you decide on your sum assured. It's advisable to select a higher cover. At the same time, the cover shouldn't be high enough for you to dig into your pockets for paying the premium. For instance, if the insurance policy states that the hospital bed cost will be 2% of your sum assured, then it'll pay Rs2,000 against a ?1 lakh sum assured, for each day of hospitalisation. But if the hospital charges you Rs3,200 in this regard, then you have to pay the balance ?1,200 from your own pocket.
Co-pay and Sub-Limits
Some health insurance companies have introduced the co-pay and sub-limit system to prevent hospitals from billing unreasonable room rents to patients. In a co-pay policy, you need to pay a part of the expenses irrespective of the sum assured. For instance, if a policy has 10% co-pay, then the insurance company will pay 90% of the expenses and you have to bear the rest. Besides, some insurers cap the expenses of treatments to reduce the claims of hospitals. This is known as sub-limit. While buying a mediclaim, choose a policy which has fewer sub-limits. Some mediclaim policies have no co-pay or sub-limits. Try to select such a plan.
Some employers provide health insurance to their staff under group insurance plan. But you can still have a mediclaim of your own which covers the entire family. You may not consider having a second mediclaim policy if your employer allows you transfer the policy if you leave your job. It's important that you compare several policies before buying one.
Majority of the comprehensive mediclaim policies cover critical illness. You don't need to purchase another policy. It's advisable to subscribe to a comprehensive plan and then top it up with an accident insurance plan which doesn't cost much. In most cases, these two policies are enough to serve your mediclaim needs. If there's a family history of a certain illness like thyroid or blood sugar, you should ideally buy a separate critical illness mediclaim. If your family has no such history, then there's no need for a critical illness plan.
The restore benefit feature allows reinstating your basic sum assured, if you have already exhausted the same as well as the multiplier benefit within your policy year. But in most cases, the benefit is not available on the same illness if the limit is already used up.
But a restoration benefit can be useful if you have subscribed to a family floater plan where the full sum assured is exhausted for treating only a single family member. The remaining members will have no cover to fall back upon in case of hospitalisation for the rest of the policy year. The rest of the members, in such a case, can get covered for other ailments than the one for which expenses have been already paid by the insurance company.
No claims bonus (NCB)
Insurers usually extend a NCB to a policyholder if there has been no claim in the preceding year. While buying a mediclaim, check the NCB amount before signing on the dotted lines. NCBs can range from 5% to even 100% of the sum insured. A high NCB gives cover against medical inflation and you don't need to worry about increasing your coverage year-on-year.
Pre-existing illness, waiting period, exclusions
Pre-existing diseases are the ones you have while subscribing to the mediclaim policy. Most health insurance companies specify a waiting period for these illnesses. If you have a pre-existing illness, the insurance company is unlikely to give a cover against the same. In most cases, a pre-existing illness is covered after at least two years of buying the policy.
Exclusions simply mean the diseases that are not covered under the mediclaim. For instance, if you suffer from diabetes while taking the policy, then kidney ailments are likely to be excluded from cover if the same happens because of the diabetes. Never hide any pre-existing ailments from your insurer while buying a mediclaim policy. It may reduce your hospitalisation claims.
Most health insurers provide free health checkup to the policyholder. But what's termed "free" is actually not such. The cost of the checkup is included in the premium. Buy such a policy only when you are keen to get the facility each year. Also check whether the mediclaim policy, renewed every year, gives coverage for the entire life. This is important because life expectancy is increasing due to improved medical technology. While most insurance companies give full life coverage, some provide cover only up to 75-80 years.
Maternity and Daycare
Some newly launched Medical insurance policies provide cover on hospitalisation that doesn't require overnight stay. These are called daycare procedures. Check out how many procedures are covered in the plan. Also, most insurers don't consider maternity as medical emergency. So don't look for a maternity cover if you have no plans for a baby.
Top up Plans
Medical costs are increasing. It calls for large covers. But not all can afford a high premium. A top up plan can come useful in such a case. It reduces cost of deductibles i.e. the amount you pay before the insurance company pays up. The insurance company will only pay up to the sum assured. A top up plan, on the other hand, doesn't pay until the hospital bill breaches a specific limit. Say, if the hospital bill is ?8 lakhs with Rs3 lakhs as deductible, you need to pay the latter, while the insurer pays the balance Rs5 lakhs. But you can use your individual/group policy to pay the deductible amount. This is usually helpful because combination of a basic mediclaim plan along with a top up plan is much cheaper than a single cover. For instance, premium for a Rs5 lakhs regular cover for a 26-year old male, will be around Rs6,500. A top up with Rs15 lakh cover will entail an additional premium of Rs5,000, which is far cheaper than a standalone policy of identical amount.
Before buying health insurance, we are sure you must be having a lot many questions in your mind. Do not worry as we at PolicyX.com are here to help you figure out the best insurance policy for you.
1. What is health insurance?
As the name implies, health insurance is a type of insurance which covers your medical bills. It's also popularly known as mediclaim in India and is a contract between an insurer and a person or a group of individuals, where the insurer pledges to provide specific medical insurance cover, against a fixed amount of "premium", which is usually paid annually.
2. What forms of health insurance are available in India?
The most popular form of health insurance policy available in India is the one that covers expenses incurred in case of hospitalisation. However, several other products are available from various insurance companies that offer an exhaustive range of health covers, depending upon the choice and need of an individual. The insurer, in most cases, directly pays off the hospital (known as cashless facility). It may also reimburse the cost associated with injuries or illnesses or disburse a fixed amount on occurrence of an illness. The amount and type of healthcare costs to be provided by the insurer under the plan is specified in advance in the offer document.
3. Why is Medical insurance important?
Every individual must buy a health insurance policy for all the members of his/her family, according to need and capacity. Subscribing to Medical insurance will cover you from sudden and unexpected cost of hospitalisation, and other serious health issues, like critical illness. Not having a health insurance policy could hugely impact your income and household savings, and may even land you in debts.
All of us are exposed to different types of health hazards. Medical emergencies are known to strike sans any warning. Healthcare, at the same time, has become increasingly expensive. New procedures, technological development, and better medicines have triggered a rise in the cost of healthcare. These expenses are beyond the reach of most of us, and buying a health insurance policy is much more affordable, to pay off the medical bills.
4. What type of health insurance plans is available today?
Health insurance is available from as low as Rs5,000 sum insured in case of micro-insurance policies to as high as Rs50 lakhs or even more than that in case of some critical illnesses. Most insurance companies offer health covers between Rs1-5 lakhs sum insured. With cabin rent and other costs payable by insurance companies being increasingly linked to the sum insured, it's advisable to take an adequate cover as early as possible, especially because the sum insured may not be increased in the event of a claim. Besides, while most Medical insurance policies are for an one year duration, there are schemes that cover for up to five years as well. Longer duration policies are also available. A hospitalisation policy either covers partly or fully the treatment cost incurred because of hospital admission during the policy period.
There's also a wider coverage that includes expenses both before and after hospitalisation. Such policies are usually available on family floater basis, or personal sum insured basis. In the former, the sum insured is spread over the family members. Another scheme, the hospital daily cash benefit policy, extends a daily fixed sum of money for each day in hospital. There could also be a higher daily benefit cover for some specific illnesses or ICU admissions.
A critical illness policy extends a lumpsum amount when an individual is diagnosed of a particular illness. The amount is used to pay off several direct and indirect monetary consequences because of a critical illness. The plan ceases to be in operation once the lumpsum is paid off.
5. What is cashless mediclaim?
These days, most insurers have arrangements with various hospitals spread across the country as part of a network. An individual, if insured under a policy which offers cashless facility, can get treated in any hospital of the network without paying hospital bills because the same is paid directly by the third party administrator (TPA), on behalf of the insurer. However, all expenses beyond the sum insured or the ones not covered under the policy, have to be paid by the insured directly to the hospital. Cashless facility is not available if the hospital is not included in the network. In such cases, payment by the insurance company to the hospital, is usually carried out on reimbursement basis.
6. What are the tax benefits of health insurance?
You can claim several tax benefits if you subscribe to a health insurance scheme. Such benefits are extended by section 80D of the Income Tax Act. Presently, subscribers to a health insurance, who purchased the policy by a payment mode other than cash, are eligible for Rs15,000 annual deduction from their taxable income for payment of health insurance premium for self, dependent children, or spouse. The deduction is higher for senior citizens at ?20,000. Also, since the 2008-09 financial year, an additional deduction of Rs15,000 can be claimed for mediclaim premium paid for parents. It's Rs20,000 if parents are senior citizens.
7. What factors affect the premium payable for a health insurance policy?
Age is the biggest factor which determines the premium payable. The older you are, the higher will be your premium, because you'll be more prone to illness. Your medical history is another factor that will go into determining the premium. If you don't have any medical history, the premium would be naturally lower. You are eligible for a discount on further premium payable for the years for which there has been no claim of the insurance money. Some insurance companies cover add-on benefits like free medical checkups and/or diagnostic tests in case of no claim.
8. What are the things not covered under a health insurance policy?
Read the offer document/prospectus and understand it fully before signing on the dotted lines. What's not included will be clearly written in the prospectus. Any pre-existing illness, usually, is not covered under a policy. But read the offer document to understand what the insurer means by pre-existing illness. Also, majority of the policies generally exclude certain types of diseases in the first year of coverage. A waiting period is also often imposed on such diseases. Some expenses not covered under most health insurance policies include cost of contact lenses, spectacles and hearing aids, dental surgery (unless it requires hospitalisation), general debility, convalescence, venereal disease, congenital external defects, use of drugs and alcohol, intentional self-injury, expenses for diagnosis, AIDS, X-ray and/or laboratory tests not connected with the illness requiring hospitalisation, treatment related to pregnancy or childbirth, including C-section, naturopathy treatment and others as deemed exclusive by the insurer.
9. What about the waiting period?
As already said, there is usually a 30-day waiting period when you buy a new policy, starting from the day you enrolled in the health insurance scheme. During this period, the insurance company won't pay any hospitalisation charges. But this is not applicable in case of an emergency hospitalisation arising out of an accident. The waiting period is not applicable for renewal of the policy for subsequent years.
10. What is a pre-existing condition?
It's a medical condition or an ailment that existed before you took the health insurance policy. This is a significant point in all policies because insurers don't cover such conditions within 48 months prior to taking the first policy. It means a pre-existing condition may be considered for payment, only after the completion of 48 months of continuous insurance cover.
11. If I don't renew my policy before the expiry date, can I be denied renewal?
The policy can be renewed if you pay your premium within the grace period, which is usually 15 days from the date of expiry of the polciy for most insurance companies. However, you will not be entitled to any coverage for the period during which the insurance company did not receive any premium. Also, the policy would lapse if premium is not paid within the grace period.
12. Is my health insurance policy transferable, sans losing renewal benefits?
Yes. According to a circular issued by the Insurance Regulatory and Development Authority (IRDA), with effect from 1 October, 2011, the insured can transfer a policy from one insurer to another, and also from one plan to another. The insured will lose no renewal credit for pre-existing health conditions which he/she enjoyed in the incumbent policy. But the credit would be limited to sum insured and the bonus eligible under the present policy. Check with your insurance company for the detailed clauses in this regard.
13. What happens to the coverage amount when a claim is filed?
Once an insurance claim is filed and settled, the coverage gets reduced by the amount paid on settlement. For instance, if you take a Rs5 lakh mediclaim policy in January, and in April, the insurance company pays ?3 lakhs towards your hospitalisation and treatment, then you will be eligible for the balance Rs2 lakhs as coverage for the remaining duration i.e. May to December
14. What about "any one illness"?
This means a continued period of illness and includes relapse within a specified number of days, subject to the terms and conditions written in the policy. It's usually 45 days.
15. How many claims are allowed in a year?
There's no limit to the number of claims in a single year, unless there's a specific cap laid down in the policy. The sum insured, however, is the maximum claimable limit under the mediclaim policy.
16. What is a family floater?
In a family floater scheme, a single policy covers the hospitalisation expenses of the entire family. Such a policy has only one sum insured which can be utilised by a single or all members collectively in the family. The limit of coverage is capped at the sum assured. Family floater plans are considered better than buying a separate health policy for each member of the family. It takes care of all medical expenses including surgeries, sudden illness and accidents.
17. What is a health checkup facility?
Some insurance companies reimburse general health checkup expenses usually once in every four years.
Health insurance is one of the fastest growing segments in general insurance. With over 20000 crore of premium in FY13, it constitutes about 28% of the total general insurance market in India. There are about 28 companies operating in India offering health plans. Most companies are now launching online plans as well to tap the growing demand for online insurance products. There are 6 public companies and 22 private companies.
Following chart provides market size in terms of premium for all private companies offering health insurance plans in India. Comparing the size of private companies with public companies would not be fair as private companies were allowed to start operating from 2001 onwards compared to public companies that have been operating for more than 50 years.
Aggregate Rating for Health Insurance [ 112 ]
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