| 1. |
What is health insurance? |
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Health insurance is a contract entered between a customer (the insured) and an insurance company (the insurer), wherein the insurer agrees to pay the insured for health care expenses that might arise due to hospitalization, accident, illness, or disease. All these expenses are subject to limits defined in the contract. Typically, the expenses covered are categorized into - hospital room charges, doctor/surgeon fees, medical tests, medicines and related expenses. The contract can be renewable annually or monthly. |
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The term health insurance is generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. It may be provided through a government-sponsored social insurance program, or from private insurance companies. It may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government. |
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| 2. |
How does health insurance work? |
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Health insurance works by estimating the overall risk of healthcare expenses and developing a routine finance structure (such as a monthly premium or annual tax) that will ensure that money is available to pay for the healthcare benefits specified in the insurance agreement. The benefit is administered by a central organization, most often either a government agency or a private or not-for-profit entity operating a health plan. |
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| 3. |
Do I need health insurance? |
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Yes, health insurance IS essential. In today’s lifestyle anything can happen to anyone at anytime without warning. One can get into a serious accident or one can catch a very serious illness or one can get heart attack all of a sudden. In this type of situation if one has health insurance he/she doesn’t need to worry for future health expenses to be bore on their own. With the rising health care cost it is wise on one’s path to invest few money on their health insurance as it helps immensely afterwards. |
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According to recent studies, healthcare costs have been rising at more than 20 per cent on an annualized basis. Also, out-of-pocket spending continues to be around 75 per cent of the total medical expenses. Given this increasing cost of medical care and treatment, it becomes essential that you have adequate health insurance cover to reduce the risk of financial difficulties in the event of a major illness or hospitalization. Even the government is getting into the act - to reduce the exorbitant out-of-pocket spending, it has been promoting low-cost health care plans. |
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4. |
Why do i need health insurance? |
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· It helps to secure expenses for future illnesses and hospitalization by paying a fraction of the expenses as the insurance premium |
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· It reduces the risk of financial meltdown in the case of expensive medical care as well as post-illness care |
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· It definitely induces a sense of security in the insured - even in the face of rising medical costs, his/her family have a financial back-up in the event of sudden medical emergencies. |
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One Can Buy Health Insurance & get tax benefit on the premium paid under section 80D of the Income Tax Act |
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Critical Care protects you or your spouse against loss of income on diagnosis of Cancer, Bypass Surgery, Heart Attack, Kidney Failure, Major Organ Transplant, Stroke, Paralysis, Heart Valve Replacement Surgery or Multiple Sclerosis. |
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Critical Care Insurance also provides cover against accidental death and permanent total disablement (PTD). |
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| 5. |
Health Insurance Terminologies |
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Premium: The amount the policy-holder pays to the health plan each month to purchase health coverage. |
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Deductible: The amount that the policy-holder must pay out-of-pocket before the health plan pays its share. For example, a policy-holder might have to pay a $500 deductible per year, before any of their health care is covered by the health plan. It may take several doctor's visits or prescription refills before the policy-holder reaches the deductible and the health plan starts to pay for care. |
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Copayment: The amount that the policy-holder must pay out of pocket before the health plan pays for a particular visit or service. For example, a policy-holder might pay a Rs.5000 copayment for a doctor's visit, or to obtain a prescription. A copayment must be paid each time a particular service is obtained. |
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Coinsurance: Instead of paying a fixed amount up front (a copayment), the policy-holder must pay a percentage of the total cost. For example, the member might have to pay 20% of the cost of a surgery, while the health plan pays the other 80%. Because there is no upper limit on coinsurance, the policy-holder can end up owing very little, or a significant amount, depending on the actual costs of the services they obtain. |
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Exclusions: Not all services are covered. The policy-holder is generally expected to pay the full cost of non-covered services out of their own pocket. |
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Coverage limits: Some health plans only pay for health care up to a certain dollar amount. The policy-holder may be expected to pay any charges in excess of the health plan's maximum payment for a specific service. In addition, some plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when they reach the benefit maximum and the policy-holder must pay all remaining costs. |
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Out-of-pocket maximums: Similar to coverage limits, except that in this case, the member's payment obligation ends when they reach the out-of-pocket maximum, and the health plan pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category (such as prescription drugs) or can apply to all coverage provided during a specific benefit year. |
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Capitation: An amount paid by an insurer to a health care provider, for which the provider agrees to treat all members of the insurer. |
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In-Network Provider: A health care provider on a list of providers preselected by the insurer. The insurer will offer discounted coinsurance or copayments, or additional benefits, to a plan member to see an in-network provider. Generally, providers in network are providers who have a contract with the insurer to accept rates further discounted from the "usual and customary" charges the insurer pays to out-of-network providers. |
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Prescription drug plans are a form of insurance offered through some employer benefit plans, where the patient pays a copayment and the prescription drug insurance part or all of the balance for drugs covered in the formulary of the plan. |
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Some, if not most, health care providers in the India will agree to bill the insurance company if patients are willing to sign an agreement that they will be responsible for the amount that the insurance company doesn't pay. The insurance company pays out of network providers according to "reasonable and customary" charges, which may be less than the provider's usual fee. The provider may also have a separate contract with the insurer to accept what amounts to a discounted rate or capitation to the provider's standard charges. It generally costs the patient less to use an in-network provider. |
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| 6. |
Which Indian companies offer Health Insurance? |
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Some of Indian companies Offering Health Insurance are as follows:
- ICICI Lombard
- Bajaj Allianz
- Apollo DKV
- Reliance General
- Cholamandlam MS
- IFFCO-TOKIO
- Star Health
- Royal Sundaram
- New India Assurance
- National Insurance
- United India
- Oriental Insurance
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| 7. |
What are the main health policies or schemes offered by Indian insurance companies? |
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The following are the health insurance policies that are available in India |
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Mediclaim Policy |
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Personal Accident – Individual |
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Personal Accident – Family |
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Group Accident Insurance |
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Jan Arogya Bima Policy |
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Bhavishya Arogya Policy (Insurance for senior citizens) |
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Traffic Accident Policy |
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Overseas Mediclaim Policy |
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The Life Insurance Corporation (LIC) offers: |
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The Asha Deep Plan: It provides cover for cancer, paralytic stroke, renal failure and coronary artery disease.
Jeevan Asha: The Jeevan Asha policy is the other healthcare product offered by LIC. |
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| 8. |
What is a TPA? |
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Third Party Administration (TPA) is a service given to a Mediclaim policyholder by providing cashless facility for all hospitalizations that come under the scope of his/her Mediclaim policy. |
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9. |
What are the benefits of TPA to a policyholder? |
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The policy holder will have full freedom to choose the hospitals from the respective TPA’s empanelled network and utilize the services as per his choice |
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• For every hospitalization, the policyholder will be well aware whether the treatment he is to undergo is covered under his policy or not. If covered, then he can seek cashless facility at any of the respective TPA’s Network hospitals. |
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• During the time of Emergency Hospitalization, the policyholder or relative can flash the Photo ID Card of the policyholder and gain admission into any of the network hospitals. No amount is to be paid at the time of discharge too. Thus, the Individual does not have to run around for arranging cash to pay for the hospital expenses. Also TPAs have ambulance referral, surgeon's referral and specialist's referral. |
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| 10. |
What are the facilities offered by a TPA? |
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1 A 24 X 7 assistance to all policy holders through toll free number of the TPA
2 Online assistance during hospitalization and filing of claim documents
3 Assistance in providing Ambulance Services during Emergency 3 Enrollment Card against your policy, which would give you access to TPA services.
4 Cash Less service facilitation at network hospitals up to limit authorized by Med claim/Hospitalization Insurance
5 Claims Processing and Reimbursement for non-network hospitals
6 Other services as defined by your Employer / Insurer |
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| 11. |
What do you mean by Network /Non-network Hospitalization? |
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A Hospital, which has an agreement with aTPA for providing Cashless treatment, is referred to as a 'Network Hospital'. Cashless facility is provided ONLY at the network hospitals. Non-network hospitals are those who have not agreed to the TPA terms and conditions and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim as per normal procedure. |
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| 12. |
What is Cashless access/Cashless Facility? |
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This means you can walk into any of the network hospitals across the country and get treated without having to pay for your bills first and then claim from the company. If you do not get admitted to a networked hospital, your expenses will be reimbursed on receipt of complete documents from you. |
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| 13. |
How to avail Cashless Facility? |
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Cash Less facility is available only in network hospitals. In case the patient wants to be referred to a network hospital the TPA needs to obtain the following documents from the patient before issuing a preadmission authorization for cash less facility:
1. Original first prescription of the doctor referring the hospitalization, complete with details of symptoms and diagnosis on his/her prescription letter head.
2. Hospitalization Form in the given format
3. Details of previous policies : if the details are not already available with TPA except in case of accidents |
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| 14. |
How does age affect health insurance plan? |
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Age definitely affects insurance plan in terms of coverage as well as cost. The older age are, the costlier health insurance premiums. |
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As one grows older, their body becomes increasingly prone to illnesses, disorders, and malaise - hence the increased insurance premium costs. |
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| 15. |
How will health insurance cover help beyond my critical illness cover on life? |
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Generally, one is advised that if they are already covered for critical illnesses on their life insurance plan and the insured amount is sufficient, they need not purchase a separate health insurance policy. |
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But, a critical illness rider covers ONLY the critical illnesses specified in the policy - they do not consider hospitalization of ANY OTHER illnesses, disease, or injury. The insurer provides the insured with a lump sum immediately or within a few days of diagnosis of the specified critical illness. Typically, the plan ceases once this sum has been paid to the insured (although some insurers offer to cover the insured for the remaining specified illnesses at a lower premium rate and for a lower sum assured.) |
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A health insurance plan, on the other hand, would entitle you to be reimbursed in case of hospitalization for any illness, disease, or injury, as long as it is within the purview of the policy. More importantly, the policy is in force even after a claim has been made. |
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The best way to go would be a health insurance plan that includes a critical illness rider where the sum assured is automatically doubled in the event of a critical illness. |
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For example, a person purchases a health plan for Rs. 2 lakhs with a critical illness rider and then suffers from a heart attack. Expenses work out to Rs. 3.5 lakh. Since the person has a critical illness rider built into his/her health insurance plan, he/she can make claims including post-hospitalization costs of up to Rs. 4 lakh. |
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If this person had not purchased the critical illness rider, he/she would have been able to make a claim up to only the sum assured i.e. Rs. 2 lakh. |
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General health insurance plans typically provide for hospital room charges, doctor/surgeon fees, medical tests, medicines and related expenses |
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| 16. |
What is Specific health plans? |
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Specific health insurance plans provide cover for critical illnesses/diseases such as heart attack, kidney failure, etc; most insurers offer critical illness plans. Another set of specific insurance plans target ailments such as diabetes and cancer. These plans offer cash on hospitalization, reimbursement for expenses incurred on surgical treatments, and such like. |
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| 17. |
Is maternity benefit available under an individual Health Insurance Plan? |
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No maternity benefit is available under individual health insurance plans. However, it may be available on a group plan; this varies from company to company. |
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| 18. |
How to decide if a disease is a pre-existing one or not? |
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At the time of purchasing a health insurance plan, you are required to fill a form stating the illnesses suffered during your lifetime. The illnesses declared at the time of filling the form are considered to be pre-existing diseases. |
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| 19. |
Is it alright not to disclose my blood pressure or diabetes problems? |
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It is prudent to be truthful when making disclosures about your existing health problems (even if your agent might ask you to avoid mentioning them), since the insurance company is not liable to pay for any claims in case of misrepresentation of facts. |
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At the time of purchasing insurance, one must be aware of the diseases or illnesses they have suffered from and the treatment they are going through, if any. Insurers refer health issues to their medical panels to differentiate between pre-existing and newly contracted illnesses. |
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| 20. |
What is the amount of insurance offered by a Critical Illness policy? |
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The sum assured under critical illness insurance ranges from Rs.100,000 to Rs. 50,00,000. A few insurance companies even offer smaller sums (Rs. 50,000) as part of a comprehensive health insurance package. |
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| 21. |
Does a Critical Illness plan cease on making a claim? |
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Usually, the policy ceases in the event of a claim. However, certain insurance plans offer to cover the insured for the remaining critical illnesses, at a lower sum assured and a revised insurance premium. |
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| 22. |
For how long is a Critical Illness policy issued? |
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Usually, a critical illness policy is issued for a period of one year. Some insurers offer to provide the insured for a term of two to five years while a few offer it for a period of 10 years to 30 years; with the premium remaining constant for three years or five years. |
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| 23. |
What is the meaning of domiciliary hospitalization? |
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When the condition of the patient is such that she/he cannot be moved to the hospital or when there is no bed available in any of the hospitals, the treatment is administered at the patient's home. Importantly, the treatment is reimbursable under the health plan only if the treatment is comparable to that provided at a hospital or a nursing home. |
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Usually, the limit of compensation is low and does not apply to certain diseases, such as asthma, bronchitis, diabetes, epilepsy, etc. |
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| 24. |
If a claim has been made for a particular ailment, does it become a pre-existing disease for the next policy term? |
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An ailment for which a claim has been made already does not become a pre-existent disease if there is no break in the term of the insurance policy and it is renewed by the due date. However, the ailment becomes a pre-existent disease and exclusions will apply in the event there is a break in the term of insurance. A break of up to 7 days is allowed under certain conditions; although it may vary by company. |
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| 25. |
If I am already covered by my office for health insurance, will it cover for ones holiday in Singapore? |
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For an overseas journey, you need the overseas health or travel insurance plan. You should check with your office regarding the type of health insurance cover provided when you are traveling abroad on company business, and then act accordingly. |
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| 26. |
If one is suffering from blood pressure and diabetes and gets admitted for a heart ailment, can she/he still claim for the same? |
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Insurers will not pay for heart ailments during the first four or five years of a health plan in force since heart ailments are considered as a complication of a pre-existing condition. |
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| 27. |
Is there a limit as to how long one can stay in hospital? |
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There is no limit as to how long a person can stay in hospital. There is, however, a limit to the amount that the insurer will pay as hospital charges. It is usually a room rate or a proportion of the sum insured. |
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| 28. |
What is the difference between a Health Insurance policy and a Critical Illness policy? |
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A health insurance plan would entitle the insured to be reimbursed in case of hospitalization for any illness, disease or injury as long as it is within the purview of the policy. The policy continues even after a claim has been made. |
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A critical illness plan, on the other hand, provides cover for a pre-specified/defined set of critical illnesses only; other diseases or injuries will not be covered. Here, the insurer provides the insured with a lump sum immediately or within a few days of the diagnosis of a critical illness. |
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Typically, the insurance plan ceases once the benefits have been paid to the insured, although a few insurers offer to cover the insured for the remaining illnesses at a lower sum assured and revised premium rates. |
HEALTH INSURANCE PLAN |
CRITICAL ILLNESS PLAN |
Cover for diseases / illnesses / injuries;
as long as within purview of policy |
Cover for specific Critical Illnesses only
- such as Heart Attack, Kidney Failure, Stroke |
Reimbursement of actual expenses or provision
of cashless benefit facility |
Lump sum paid within few days of diagnosis
or immediately |
Policy continues even after claim is made,
until renewal |
Policy ceases once benefit has been paid (few
offer the choice of remaining insured for other illnesses) |
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| 29. |
What is the difference between a Critical Illness Rider and a Critical Illness Plan? |
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A critical illness rider can be purchased as an additional benefit on your health insurance policy. You can make a claim even if you are hospitalized due to an accident or an injury or a disease i.e. for hospitalization and other expenses arising from causes other than a critical illness. |
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Furthermore, in plans that provide the rider along with the health insurance plan, the sum assured is automatically doubled. For example, suppose a person purchases a health plan with a critical illness benefit for Rs. 2 lakh and subsequently suffers a heart attack. Let's assume his expenses come up to Rs. 3.5 lakh. Because his health plan includes the critical illness benefit, he then can claim cost/expenses (including post-hospitalization costs) up to Rs. 4 lakh (2 lakh health plan plus 2 lakh critical illness benefit). Whereas, if he just had the health insurance plan without the critical illness rider, he would have had to be satisfied with a claim up to just the sum assured i.e. Rs. 2 lakh. |
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On the other hand, if you have just a critical illness plan, you can make a claim for the pre-defined critical illnesses only and not any other injury or disease. |
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In case of a critical illness plan, typically, the insured receives the sum insured on either immediately or within a few days of diagnosis, irrespective of the actual expenses. |
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| 30. |
What is Family Floater and what are its advantages? |
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Family Floater is a policy wherein the entire family of the insured, comprising of insured, spouse and two dependent children, is covered under single sum insured. |
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The advantages of such a policy are: |
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1. All members of the family (as defined above) can be covered under one policy. |
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2. Single Premium is payable for the entire family. |
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3. The amount of Sum Insured floats over the entire family i.e. the limit can be used by any member of the family and for any number of times. |
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4. One does not have to keep a track of renewals for different members; a single renewal date is to be remembered. |
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| 31. |
Can any claim be rejected or refused? |
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Yes, the claim, which is not covered under the policy conditions, can be rejected. In case you are not satisfied by the reasons for rejection, you can represent to the insurer within 15 days of such denial. |
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| 32. |
Should the claim be submitted to the Insurance Company or TPA? |
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The claim has to be submitted directly to the TPA for timely settlement |
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| 33. |
Will I get the entire amount of the claimed expenses? |
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The entire amount of the claim is payable, if it is within the Sum Insured and is related with the in-house treatment as per policy conditions and is supported by proper documents, except the expenses which are excluded. |
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| 34. |
In case of part settlement can an insured claim for the balance amount? |
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Normally, part payments are made due to deficiency of documents or for expenses which are not covered under the policy. In case of the former if the requisite documents are made available, the claim may be considered. |
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| 35. |
How can I check the status of my claim? |
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You can call the helpline number of your TPA or check on their site using your Policy number or member id. |
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| 36. |
How does one get Reimbursement for pre and post hospitalization expenses? |
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The Mediclaim Policy allows reimbursement of medical expenses incurred towards the ailment/ disease for which hospitalization was necessitated prior to hospitalization and up to a certain number of days after discharge as per the limit specified in the policy. |
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For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to your TPA. The bills must be sent to the TPA within 7 days from the date of completion of treatment. The insured must also provide the company/TPA with additional information and assistance as may be required by the company/TPA in dealing with the claim. |
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| 37. |
What is the procedure to get Reimbursement in case of emergency hospitalization? |
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1 Take admission into the hospital. |
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2 As soon as possible, inform TPA about the hospitalization |
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3 At the time of discharge, settle the hospital bills in full and collect all the original bills, documents and reports. |
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4 Lodge the claim with TPA for processing and reimbursement by duly filling in the claim form & enclosing all original bills/vouchers/receipts. |
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| 38. |
What are the situations under which one may be denied cashless hospitalization? |
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1 If there is any doubt in the coverage of treatment of present ailment under the Policy |
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2 If the information sent to TPA is insufficient to confirm coverage |
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3 If the ailment/condition is not being covered under the policy |
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4 If the request for pre-authorization is not received by TPA in time |
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In such a situation, the Insured can take the treatment, pay for the treatment to the hospital and after discharge, send the claim to TPA for processing. |
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| 39. |
For how many days would the pre and post hospitalization expenses be covered? |
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The period varies according to the insurer and the plan opted for. |
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Insurer
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Pre hospitalization/Post hospitalization
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National Individual
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30 days/60 days
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National Parivaar
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15 days/30 days
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National Varistha
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30 days/60 days
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New India
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30 days/60 days
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United
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30 days/60 days
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Oriental
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30 days/60 days
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Bajaj Allianz
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60 days/90 days
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ITGI
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30 days/60 days
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Royal Sundaram
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30 days/60 days
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Reliance Gold and Silver Plans
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60 days/90 days
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Reliance Standard Plans
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30 days/60 days
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| 40. |
Is there a tax deduction on the premium paid? |
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Premiums paid up to Rs. 10,000 per annum under the health insurance plan for self, spouse, two dependent children and dependent parents are exempt from tax under section 80 D of the Income Tax Act. |
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| 41. |
Can I get a refund if I cancel my health insurance plan during the contract term? |
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Yes. The insurer is liable to refund the premium if no claim has been made up to the date of cancellation. |