Health Insurance policies protect you against spiraling medical costs and manage your and your family's health-related needs right from consultation, hospitalisation to post-hospitalisation. For a certain premium payment, health insurance policies cover many aspects of your health care including room and boarding expenses when hospitalized, doctors' fees including those of specialists, pre and post hospitalization expenses, ambulance expenses and many other costs related to any medical issues that you or your family may encounter. Each policy has a sum assured (which is choosen by the policy holder) based on which the premium amount is computed and coverage amounts for various types of benefits are determined. For instance, one policy may provide for 1% of the sum assured for ambulance costs.
The premium you pay for a health insurance policy is exempt under Section 80D of the Income Tax Act. Premium up to Rs.15,000 per year qualifies for this tax benefit under Section 80D of Income Tax Act. Tax benefit goes to the person making payment, persons covered can be his/her dependants (spouse, children). A higher amount of upto Rs 20,000 is permitted if the person, for whose health insurance the premium was paid, was aged 65 years or more at any time during the financial year in which the premium was paid. Section 80D benefit is over and above the Rs. 1 Lakh benefit of 80C (ELSS, Principal component of home loan, Life Insurance etc.).
Different companies have different requirements for this. Some companies do not require a medical checkup for people under a certain age (such as 45 or 50 years), while others may require a medical checkup depending on the sum assured and the age of the insured.
A Family Floater is a single policy that takes care of the hospitalization expenses of your entire family. A Family Floater Health Plan takes care of all the medical expenses of the entire family during sudden illness, surgeries and accidents. A Family Floater Policy has a single sum assured that applies to costs for all family members on the policy.
Cashless facility is the ability to get medical services without paying any cash, by showing your health insurance card. Most health insurance policies support cashless facility, but only in hospitals in their network. If you visit hospitals within the network of hospitals provided by the health insurance company, you do not have to pay for the medical costs under the cashless facility. Otherwise you may have to pay cash for your treatment. Some policies will reimburse you for your treatment costs in out of network hospitals.
TPA stands for Third Party Administration. The TPA referred to in health insurance policy documents is your contact to health insurance companies. TPA is working on behalf of health insurance companies and provides you with all of the services which are promised in your policy. Typically in case of an insured event you are supposed to contact the TPA for intimation, request for authorization and claiming of benefits.
Pre and Post hospitalization expenses refer to expenses incurred prior to and after hospitalization due to a medical condition. For example, a person maybe required to undergo certain tests to confirm the disease for which he or she is eventually hospitalized. The Doctor's consultation fees for this, the expenses on tests and medicines prior to hospitalization for that particular disease fall under the category of Pre hospitalization expenses. Subsequent follow up consultations with specialists, medicines and test expenses after a person has been hospitalized and discharged fall under the category of Post hospitalization expenses. Typically, health insurance policies cover expenses for a certain number of days (30, 45, 60 etc.) for Pre and Post hospitalization. The number of days provided by a health insurance plan for Pre and Post Hospitalization expenses can be a key criterion for choosing your health insurance plan. Read the product brochures for complete details.
If you are looking to buy a health insurance policy, you must understand the coverage you can get from the policy so that you can compare the different plans. Typical benefits from health insurance or mediclaim policies in India fall under the following categories:
Hospitalization Cover or in-patient expenses: Protects the insured person or family (in case of family floater plan) for in-patient hospitalization expenses as a result of suffering illness or bodily injury during the period of insurance, which on the advice of a medical practitioner requires hospitalization. These include room and boarding charges as per policy conditions.
Day care expenses or out-patient expenses: Day Care expenses incurred on advanced technological surgeries and procedures like Dialysis, Radiotherapy, and Chemotherapy, requiring less than 24 hours of hospitalisation.
Cost of Medicines and Drugs: This may include Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical
Appliances, Medicines and Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Cost of Pacemaker, Artificial Limbs and Organs and similar expenses.
Maternity Expenses: Costs incurred during child-birth are covered under this category. Different limits for coverage are typically applicable for Normal Delivery and Caesarean Delivery. Note that most policies cover maternity expenses only after a waiting period of a few years such as 4 years and 6 years. In other words, a policy holder needs to hold the policy for a certain number of years before the maternity expenses are covered by the health insurance policy.
Pre-Hospitalization Expenses: Pre-hospitalisation means relevant medical expenses incurred during a
period up to certain (typically 30) days prior to hospitalization for an illness or bodily injury sustained and considered a part of a claim admissible under the policy. For example, a person maybe required to undergo certain tests to confirm the disease for which he or she is eventually hospitalized. The Doctor's consultation fees for this, the expenses on tests and medicines prior to hospitalization for that particular disease fall under the category of Pre-hospitalization expenses. Typically, health insurance policies cover expenses for a certain number of days (most policies cover for 30 days) for Pre-hospitalization.
Post-Hospitalization Expenses: Post Hospitalisation means relevant medical expenses incurred during a
period up to certain (30, 45, 60 etc.) days after hospitalization for an illness or bodily injury sustained and considered a part of a claim admissible under the policy. Follow up consultations with specialists, medicines and test expenses after a person has been hospitalized and discharged fall under the category of Post-hospitalization expenses. Typically, health insurance policies cover expenses for a certain number of days (30, 45, 60 etc.) for Post-hospitalization.
Emergency Ambulance Expenses: Costs incurred in transporting a insured patient to the hospital subject to limits and other conditions specified in the health insurance policy.
Daily Cash for accompanying an insured child: If a insured child requires hospitalization, some policies provide daily cash to the accompanying adults.
Domiciliary Treatment: These are costs incurred for treatment of patients at home. Most insurance policies cover domiciliary treatment if it is based on a doctor's recommendation and within certain limits set under the health insurance policy.
Spectacles, Contact Lenses, Hearing Aids: Typically covered only in premium policies.
Outpatient Dental Treatment: Typically covered only in premium policies and only after a certain waiting period.
General Health Checkup: Costs incurred for periodic health checkup that is not triggered by any illness. Typically policies cover this for a small (1 or 2%) percentage of the sum assured once every 2 or 3 years. Some of the medical tests covered by this include Medical Examination Report, Blood grouping and Rh Typing, Hb%, Blood Count, Fasting Blood Sugar, ECG and Urine Routine. Check with insurance company for complete coverage details.
Cashless Hospitalization or Claim: If you have a health insurance policy that supports cashless hospitalization, it means that you can get medical treatment just by displaying your insurance card without paying any cash to the hospital. Most health insurance policies offer this benefit. However, the benefit it restricted to a certain list of hospitals specified by the health insurance company along with its policy. If you visit a hospital in-network (within the list provided by the health insurer), then you do not have to pay any cash for relevant medical expenses. You may still have to pay for expenses that are not covered by the policy rules. However, if you are admitted to a out-of-network hospital, you most likely will have to pay cash for your treatment. Depending on the policy, you may get reimbursed for such treatment by submitting a expense report to the health insurance company or its Third party Administrator (TPA). Cashless hospitalization or claim is a critical element of any health insurance policy.
For cashless hospitalization, policies may require the Insured to contact the TPA at least 48 Hours before a planned hospitalization. In an emergency situation, the rules for when the TPA must be intimated may be different.
It must be noted that not all policies provide all of the above benefits. The benefit coverage amounts for each of the above may also vary based on the type of policy you have taken and the company from which you are taking the health insurance policy.
A health insurance card is a card issued along with your health insurance policy. It is similar to a identity card or credit card. It allows the policy holder to avail of cashless hospitalization and other benefits by showing the card. A health card mentions the contact details and the contact numbers of the TPA. In case of a medical emergency, you can call on these numbers for queries, clarifications and for seeking any kind of assistance. Moreover, you need to display your health card at the time of admission into the hospital. Each policy holder (for instance in a family floater plan) can get his or her own health card that they can carry with them for use in case of a medical emergency.
Health insurance policies do not cover pre-existing diseases when you first take the health insurance policy. However some policies do cover pre-existing diseases after a certain waiting period subject to limits. For example, ICICI Lombard covers pre-existing diseases after 4 years provided the policy is renewed with them continuously for that period.
Companies offering health insurance policies in India include Apollo DKV, Bajaj Allianz, Cholamandalam MS General Insurance, Oriental Insurance, New India Assurance, National Insurance, Reliance General, HDFC Ergo, Royal Sundaram, Star Health, United India Insurance, Tata AIG and ICICI Lombard.
Yes, most companies provide the option of buying health insurance policies online. Note that if you have any pre-existing medical condition or need a medical test per the policy guidelines, then you may have to contact the insurance company offices for purchasing the insurance policy.