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Health Insurance

Health Insurance


There is an old saying "Health is Wealth". Indians spend more on health of their smart phones (screen guard, insurance, etc.) than on protecting their own health. Health Insurance is a protective cover for you and your family in times of need and for a small premium every year.

What is Health Insurance


Health insurance is a contract where an individual or group buys health cover by paying a fee called "premium".Health insurance is an insurance which covers your hospital bills and expenses.

There is a popular saying about health insurance: "Buy health insurance when you don't want it, because you may not get it when you want it."

Health insurance provides coverage for expenses incurred for hospitalization whether planned or an emergency. With medical inflation at approx.15% failing to hold adequate amount of health insurance cover can prove to be a major personal financial disaster. This could lead to either poor health care because of non-affordability or lead an individual into financial 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.

There are two common mistakes when it comes to buying life insurance and health insurance.
People don't act at the right time
When they realize their mistake they try to over-compensate by buying too much insurance

Today, most of the salaried professionals are covered by health insurance cover provided by their organizations. Employees are increasingly dependent on these health insurance cover to counter their health needs. They often fail to assess their health insurance requirements and don't realize the benefits of personal health Insurance. All are advised to opt for personal health insurance cover as well.

The following points signify the importance of personal health Insurance cover:

1.Increase in the incidence of lifestyle-related illnesses & Life expectancy has increased along with stress due to sedentary lifestyle leading to early onset of chronic diseases like cancer, lung conditions and stroke, claiming younger lives. Health insurance mitigates this financial risk that may occur to a person irrespective of age.

2.Increase in out-of-pocket expenses due to medical inflation. Health insurance can act as your emergency financial during your troubled times.

3.Group health cover provided by company may not be sufficient as it may or may not cover all family members. The sum insured limit in a group cover may not be adequate to meet all the medical expenses incurred.

4.Also as you grow older, you might need frequent medical attention. Before that you should buy adequate Insurance coverage.

Health Insurance Policies


There are 2 types of health insurance plans:

1.Hospitalization plans or Indemnity policy
2.Benefit plans

Hospitalization Plans or Indemnity plans:

These plans reimburse the actual hospitalization costs incurred by the individual as per the terms of the policy upto the sum insured. This is of 2 types:
1. Group or corporate insurance: This cover is provided by employers to its employees & their families. This is usually provided as an incentive at the time of joining, premium is usually paid by the employer
2. Retail or individual insurance: This cover is taken by individuals and is of further 2 subtypes:

a. Individual cover: Covers only the member who has taken the cover.Consider a family of 3 with an individual cover of Rs 2 lakhs each. Each member can claim till maximum of Rs 2 lakhs as all three policies are independent.
b. Family floater cover: Covers the entire family upto the sum insured If the family applies for a family cover for Rs 5 lakhs, then any family member can claim medical benefit upto 5 lacs as long as it is within the overall sum assured of Rs 5 lakhs


Benefit Plans

Benefit plans pay a defined amount as a single payment or per day as per the policy terms at inception irrespective of the amount incurred. Personal accident policy, hospital daily cash policy, Surgical cash policies and critical illness policies are examples of type of policy.

What is the best health insurance plan? Should I buy an individual policy or a family floater policy? These are the questions that people struggle with when looking to buy a health insurance policy.

So, look for a plan that:

Has high ratings Same can be checked by review of Industry experts and customer reviews.
Remember, a comprehensive health insurance plan help the insured stay well as well as get better after the treatment/surgery.
Is a wellness plan included ?
Hospital network of the Insurer should be checked for availability in your locality.
Has easy claim authorization and settlement process

Important factors to ponder while selecting a plan:

1.Buy health insurance at younger age and when healthy as risk and premium increase with age.


2.Waiting periods to be kept in mind
Most health insurance policies has a waiting period for 2-4 years for defined pre-existing diseases.

If a health insurance cover is taken early in life, you can easily take advantage of the waiting period rather than serving it at a later stage when your health risks may have increased.

3.Know the limits and exclusions

Sub-limits:  Most policies have sub-limits on room rent, Surgeon charges, ICU charges, OT charges and medical procedures. Choose a policy without sub-limits; it may have a higher premium but it is a better option in a long run.
Co-payment: In policies with co-payment, the insured has to bear a pre-defined percentage of the claim amount and the rest will be settled by the insurance company. Though the premiums are lower but these will not provide complete coverage.

4.Choosing adequate sum insured
Consider all personal liabilities, age of all insured members, medical inflation and current health condition before opting for the sum insured.

5.Floater or Individual plan?
If you are young and have a small nuclear familyit is better to opt for a family floater policy that covers the entire family. Compared to individual plans, family floater has a marginally higher premium.

6.opt for policies with additional coverages likeMaternity Cover, Critical Illness Rider

7.Clearly read and understand the policy wordings and understand the claim process, document requirements, payment options, special conditions, coverage and exclusions.

8. Increase in sum insured over a period of time to counter medical inflation and also to cover the increase medical needs as age related medical expenses will be higher

Pre-existing diseases

A pre-existing disease is a medical condition which is present before commencement of the policy this definition also includes any complications arising in the future from such a pre-existing disease. Most of the companies have specific waiting periods after which pre-existing diseases are covered provided the policy renewals have been continuous and without any break.

Specific waiting periods for ailments

The expenses on the treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout and Rheumatism, Calculus diseases, Joint replacement due to Degenerative Condition and age related Osteoarthritis and Osteoporosis are generally not payable until a specific period of time, which differs from company to company. The specific diseases may also differ with the company.

Treatment for dental care are not covered unless due to an accident Cosmetic surgery

Cosmetic surgery does not improve the health of an individual. It's main role and benefit lies only in external looks and beauty..

Alternative therapies: AYUSH therapies are not covered Pregnancy related expenses

How to choose your Health Insurance Policy


What is covered?

1)Hospitalization Expenses: All charges incurred during hospitaliztion as per your policy cover

2)Pre-Hospitalization: Consultation charges, Charges related to Investigations done for diagnosis before admission

3)Post hospitalization: Follow up visit and procedure charges in OPD medication charges & followup investigation charges

4)Daycare Charges: Due to advancement in technology certain surgical procedures do not require 24 hour hospitalization but are still covered by your policy. Cataract, Kidney stone surgery are examples of same.

5)Ambulance Cover: Ambulance used to transport the patient to hospital is covered by your policy as per the terms

What is not covered?

1)Cooling period: All policies have a cooling period of 30 days when policy is taken for the first time. Only accident related claims are admissible during this period.

2)Disease specific waiting period: Most of the Insurance companies have disease specific waiting period . The period varies but it is usually for 2 years. These include diseases like cataract, slip disc and others specified in the policy.

3)Pre existing disease waiting period: If you have a certain disease at time of taking policy same will not be covered for a fixed duration as per the policy terms. Usually it is for 4 years but same may vary as per the Insurance company.

4)Permanent Exclusion: There are certain ailments like Mental illness, cosmetic surgeries which are permanantly excluded. The list is mentioned in your policy copy.

Health Insurance Claim


Cashless hospitalization is a facility provided by the insurance company where the policy holder can get admitted and undergo necessary treatment without paying the hospital directly for the medical expenses

In Cashless health insurance Service, when you get hospitalized with a network hospital, you do not have to settle the bill with the hospital. The Insurance Company represented by the TPA, co-ordinates with the hospital and settles the bill

In the event that an insured is hospitalized in any hospital / nursing home and pays the treatment expenses at the time of discharge, he / she needs to file a claim with Insurance company/TPA for the amount.The same will be assessed by the Insurance company/TPA and settled as per policy terms. This is a reimbursement claim

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