Health insurance is essentially an agreement between a policyholder and the insurance company in which the insurer offers financial coverage to the policy buyer up to the limit of the sum insured. It provides medical coverage for hospitalization costs incurred during a medical emergency. The policy also covers scheduled hospitalization. It also extends tax breaks on policy premiums paid to insurance providers under Section 80D.
To know all about these in detail and more, take a quick look at the following article.
What is Covered Under a Health Insurance Policy?
Most leading health insurance providers in India cover these medical expenses under a comprehensive health insurance plan:
- In-patient Hospitalisation Expenses: The expenses incurred during hospitalisation incurred for the treatment of an injury or illness are covered under the insurance plan. However, the same is reimbursed only if the patient was hospitalised for more than 24 hours.
- Pre-existing Illnesses: Once the waiting period of the policy is over, individuals can raise a claim for expenses they have incurred to treat any pre-existing illness or medical condition.
- Pre and Post-Hospitalisation Expenses: The insurance provider covers medical expenses such as blood tests, x-rays, and other health screenings that are essential ahead of hospitalisation. In a similar way, the cost of medication and preventative health check-ups conducted after the insured is discharged from the hospital is accounted for under the health insurance.
- Ambulance Fees: While the amount of health coverage varies among insurance providers, most medical insurance policies include emergency ambulance charges in their offerings.
- Maternity Coverage: Medical expenditures incurred by the insured during pregnancy and delivery, as well as all newborn baby expenses, are covered.
- Preventive Health Check-ups: Some health insurance companies also offer regular health check-up services for the insured.
- Day-care Procedures: Daycare treatments are covered when hospitalisation is not necessary for more than 24 hours. The insurance plan typically covers eye surgery, dialysis, and other procedures listed in the policy agreement.
- Home care Coverage: Health insurance plans also cover the costs of receiving medical care at home on the recommendation of a doctor.
Besides these, health insurance plans also cover medical costs incurred on availing Ayurveda, Homeopathy, Unani, or Siddha treatment. However, the same is subject to a fixed limit. It also accounts for mental illnesses under the Mental Healthcare Act, 2017.
What is Not Covered in a Health Insurance Plan?
A health insurance policy does not cover the following medical costs and situations:
- Claims made during the first 30 days after purchasing a health insurance policy are not covered unless there’s an accidental emergency
- Pre-existing illness coverage is subject to a 2- to 4-year waiting period
- The typical waiting period for the critical illness cover to kick off is 90 days
- War/terrorism/nuclear activity-related injuries
- Suicide attempts or all self-inflicted injuries
- Terminal illnesses, AIDS, or other similar ailments
- Cosmetic/plastic surgery, hormone replacement surgery, and so on
- Dental or eye surgery
- Common diseases, bed rest, and rehabilitation
- Treatment/diagnostic testing, as well as follow-up procedures
- Injuries resulting from adventure sports
Things to Check Before Buying a Health Insurance Policy
In order to make an informed choice while buying a health insurance policy make sure to check the following carefully:
-
Scope of Coverage
Always opt for a health insurance plan with extensive coverage and benefits. When comparing plans look for health insurance that covers hospitalization charges, critical illnesses, maternity expenses, major surgeries, etc.
-
Sum Insured
The sum insured is a critical factor to check when choosing health care coverage. Given the current rate of inflation, it is recommended to purchase a health insurance policy with a minimum value insured of at least Rs 10 lakhs and a maximum sum insured of Rs. 1 crore. The higher the sum insured on a family floater policy or a senior citizen insurance plan, the better will be the coverage amount.
-
Policy Type
While there are several types of health insurance available today, it is recommended to pick one that suits your requirements. Based on your requirements you can choose a policy from among these options:
- Individual health insurance policy
- Senior citizen health insurance policy
- Family floater
- Critical illness plans
You can even choose to avail of a top-up for your existing health plan for extended coverage. This will come in handy if your sum insured gets exhausted during ongoing treatment. It is recommended to avail of a health insurance designed for senior citizens to ensure the burden doesn’t affect their retirement plans.
-
Waiting Period Clause
It is crucial to note that a health insurance policy kicks in only after the completion of the initial waiting period. So any claims excluding accidental hospitalization, if raised by the insured during this period, can get rejected right away. This is why it is important to opt for a health insurance plan that accompanies a shorter waiting period.
-
Room Rent Sub-limits
The most common kind of sub-limit in a health insurance policy is the room rent sub-limit. For example, if your medical insurance protection has an amount insured of Rs. 3 lakhs and a sub-limit of 1% on daily room rent, your room charges will be covered up to a maximum of Rs 3,000 per day. Any additional room rent must be paid by you. This is why, a health plan with no or few sub-limits is recommended.
-
Network of Cashless Hospitals
Make sure to check an insurance provider’s network of hospitals to find out the ones where cashless claims can be lodged. The greater the number of network hospitals in your area, the greater your chances of receiving cashless hospitalisation benefits.
-
Premium Loading Factor
Premium Loading is the extra amount that’s levied on a risk-prone policy buyer’s premium, particularly in senior citizen health insurance policies. You can avoid the additional burden by simply opting for a medical insurance plan with zero loading. However, you should note that some insurers also charge a claim loading. which increases out-of-the-pocket expenses when you raise a claim. Hence, make sure to double-check these premium and claim-loading aspects of an insurance policy before buying one.
-
Check the Claim Settlement Ratio
This is a crucial element for evaluating a policy provider’s claim settlement credentials. It is recommended to always pick an insurance provider with a high claim settlement ratio. Typically, a claim settlement ratio of over 80% is deemed ideal.
Intending policybuyers should keep these things in mind when looking for a health insurance plan. They should also assess their needs and requirements to make an informed pick.
