Sixteen things to know before you buy a Health Insurance Policy

The core of any Insurance plan is protection. Offering protection and alleviating your risk is the simple motive of an insurance plan. Making that small investment in any health insurance plan, will enable you to be tension-free and offer security in advance. Especially when we are facing the pandemic and the rising cost of a treatment makes it although more necessary to buy a Health Insurance Plan. As per IRDA regulation, currently all the treatment cost incurred for Covid 19 are covered under all health insurance policies.

The features breakup has been explained in 2 parts – One lesser known and the other which are generally covered. First we go through the lesser known features –

  • Second Opinion – Many insurer allow this facility for free and as an inbuilt feature from their network of medical practitioners mainly when the insured is diagnosed with the specified Critical Illness.
  • Global Cover It covers for Medical Expenses of the Insured Person incurred outside India, upto the sum insured, provided that the diagnosis was made in India and the insured travels abroad for treatment. The Medical Expenses payable shall be limited to Inpatient and day-care Hospitalization only on reimbursement basis. Cashless facility may be arranged on case to case basis. The payment of any claim under this benefit will be in Indian Rupees. Insurer requires the following additional documents supporting the claim under this benefit:

a) Proof of diagnosis in India
b) Insured’s Passport and Visa

  • Free Health Check-up / Preventive Health Check-Ups– Each insurer has this feature of providing Annual health checkup or once in each block of some claim freeyears. The eligibility of amount and the list of tests depends is as per sum insured opted. One can avail the same as cashless by scheduling an appointment or visit a center of your choice and claim as reimbursement
  • Restoration/Refill Benefits-When opted Sum Insured is insufficient due to claim, restoration benefit can be utilised. Multiple Restoration is available in a Policy Year for related or unrelated illnesses in addition to the Sum Insured opted depending upon the insurer.
  • AYUSH –AYUSH treatment refers to the medical and /or hospitalisation treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy Systems. These treatments are covered only when taken at the government Hospital or in any institute recognised by government and/or accredited by Quality Council of India/ National Accreditation Board on Health. Facilities and services availed for pleasure or rejuvenation or as apreventive aid, like beauty treatments, Panchakarma, purification,detoxification and rejuvenation etc are part of exclusions.
  • Home Hospitalisation or Domiciliary Hospitalisation: Domiciliary Hospitalization means medical treatment for an illness/ disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:

a) The state of the patient is such that he/she is not in a condition to be moved to a hospital for treatment, or

b) The patient had to take the treatment at home in the circumstances of non-availability of the room in a hospital.

  • Organ Donor- Cover for Medical and surgical Expenses of the organ donor for harvesting the organ where an Insured Person is the recipient provided that
    1. The organ donor is any individual whose organ has been made available in compliance with the rules & requirements of The Transplantation of Human Organs (Amendment) Bill, 2011 and the organ which is being donated by donor is for the use by the Insured Person, and
    2. Insurer have accepted an inpatient Hospitalization claim for the insured member under In Patient Hospitalization Treatment
  • Air AmbulanceThe air ambulance can be helpful in case of medical emergencies. It helps when one is injured during a trip and requires transport facility, in case one requires hospitalisation immediately and it is not possible to travel by road,etc.

Health insurance policy would generally cover the expenditures incurred reasonably and necessarily under the following heads –

    • Pre & Post Hospitalization – Medical expenditures incurred before & after the hospitalization provided that: Such Medical Costs were incurred for the same illness or the injury for which earlier and subsequent Hospitalisation was needed. And the number of days differs from insurer to insurer i.e. for pre hospitalisation days vary 30 days to 90 days & 60 to 180 days for post hospitalisation requirements.
    • Senior Citizen Plans- There are special plans specifically designed for senior citizens and while buying them following points are to be considered – waiting period for pre-existing disease, Co-payment, Entry age, pre-policy medicals etc.
    • No Claim Bonus- In the event of no claim in the policy year, insurer adds a fixed percentage depending upon the product say from 10% rise each claim free year subject to maximum 100% of the sum insured or even some insured offer cumulative bonus not in excess of 200% of the sum insured under the current policy.
    • Day Care Procedures –Generally an insurer covers listed Day Care Treatment due to disease/illness/Injury during the policy period taken at a hospital or a Day Care Centre. The list of treatment varies from insurer to insurer. The scope of the policy cover does not include the treatment normally taken on an out-patient basis.\
    • Pre – Existing Diseases  – Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment was received within specified months prior to the first policy issued by the insurer and renewed continuously thereafter.
    • Waiting Period- Any benefits related to pre-existing condition, ailment or injury until the defined waiting period since inception of policy, provided the pre-existing condition is disclosed in the proposal form. Claim would also not be paid for specified diseases         like Cataract, stones in the urinary and biliary systems, all types of sinuses, joint replacement surgery, bariatric surgery etc. until 24 to 36 months of waiting period depending upon the insurer.
    • Maternity Expenses – Most of the insurer do cover maternity benefits with specified waiting period ranging from 9 months to 72 months, the maternity cover depends upon the sum insured and covers normal delivery, C section, lawful termination of pregnancy and infertility treatment too.
    • Newborn Baby Cover – It would cover Medical Expenses incurred towards treatment as inpatient for delivery, Coverage considered under the maternity cover upto 90 days after birth and within limit of sum insured without paying any additional premium. Mandatory Vaccinations of the newborn baby up to 90 days, as recommended by the Indian Pediatric Association will be covered under the Maternity Expenses. Many insurers offer Reasonable and Customary charges for vaccination expenses for the Newborn Baby as per National Immunization Scheme (India) listed below, till the baby completes 1 year (12 months) upto the limits specified in the Schedule.

–          Authored by Ms. Nisha Sanghavi,

 Founder Fynomics and Co-founder Promore Fintech Private Limited.