Buying from a broker is like insuring your risk of “insuring a risk”.
You can buy personal health insurance from Broker, Agent, Directly from the Insurance company office or from their website or Online from a web aggregator website.
An Insurance broker is bound by the Insurance Regulator to perform as per the terms laid to them. They need to protect the interest of the client (you) at every step of insurance, be it buying or claiming assistance and representing the clients to the Insurer and not the other way around. That is why they are the only legal entity which is not tied with any particular Insurance company. They can deal with any Insurance company.
Now, because they are experienced and have worked with various clients, they know the best practices and hence can help you set up the best insurance policy for your organisation with ease, saving your time and effort.
If an Insurer wants to shift to a new Insurer because of additional benefits or for a better service then he can do so by following the portability guidelines.
An insured can change his insurer and get a waiver on the waiting periods as below
The waiting period waiver is given to the extent of the claim free years he is present in the current policy and is limited to the current policy sum insured.
If he takes the policy with higher sum insured then the current policy, then the waiting period will be applicable as mentioned in the new policy.
A person can shift from group policy to retail health insurance policy by taking help of portability guidelines. To check the latest guidelines Click Here
1. Health Insurance Is Only for Healthy People:
Health insurance is only for healthy people as most of the pre-existing diseases are not covered under many plans. Even if any of the plans offer the coverage of pre-existing diseases it comes with a hidden fact that certain waiting periods must be completed before covering pre-existing disease in the taken plan. Therefore, if you are expecting health insurance to cover any disease then you must take insurance when you are healthy, i.e. now.
2. Increasing Gap Between Affordability and Capacity:
The cost of treatment rose at a double-digit pace of growth, outpacing average inflation in both rural and urban India over the past decade, according to published results of a cross-national survey on health conducted by the National Sample Survey Office (NSSO) in 2014 quoted in Live Mint. In simple terms, with the rising cost of treatment health care is becoming unaffordable. Visiting private hospitals for basic consultation itself is creating a huge burden on the pocket. On the other hand the salaries, allowances are not rising at the same pace. This means a gap between the affordability of treatment and earning capacity is increasing. Hence, it will become more and more difficult to take care of hospital expenses from pocket today and in times to come.
3. The pace of discoveries of new diseases:
Scientific techniques are improving, so are discoveries of new diseases. During the past 20 years, at least 30 new diseases have emerged, for many of which there is no treatment, cure or vaccine, or the possibility of effective prevention or control. In addition, the uncontrolled and inappropriate use of antibiotics has resulted in increased antimicrobial resistance and is seriously threatening drug control strategies against such common diseases as tuberculosis, malaria, cholera, dysentery, and pneumonia. Though “prevention is better than cure” is a trend which is bringing in health awareness to recuse lifestyle-related diseases but not offering any solution to new diseases. Has anyone heard about chikungunya, dengue, bird flu, swine flu, Ebola, etc. in childhood? So when is time for health insurance, if not now?
4. Advancement in medical technology is a blessing but it comes at a cost.
Researchers and physicians have made great strides toward finding a new, more effective treatment for the diseases, even ones considered non-treatable. The techniques of diagnosis also have taken a leap to the genetic factor drilling to its correction. New treatments invented are very effective but are very expensive too. Say for example Laparoscopic surgeries decreased the time of recovery to less than half but increased the cost of treatment to 10 times. Similarly, the cost of Robotic surgeries or stem cell treatment is out of reach for a common man’s pocket although they offer a more effective solution. The risk of requiring such expensive treatments can be transferred by having appropriate health insurance.
Health insurance is as important as having a mobile wallet in times of demonetization. Health Insurance is an inevitable weapon for the times of need – which one must have now!!!
Claim is admissible only when the Insured gets admitted in hospital for a minimum of 24 hours.
With the advancement in Science and Technology, there are certain surgeries which do not require 24 hours hospitalization. They take more than 2 hours,and are also expensive. This is where a compulsory 24 hours hospitalization clause needed relaxation to include such expenses. Because this was causing moral hazard as insured and the hospital with mutual understanding extended hospitalization to 24 hours to get coverage. Either in real time or just in papers.
Insurers have listed around many such treatments called “Day care procedures” where and allow the medical coverage even if 24 hours minimum hospitalization is not given. Even if it is not listed, you can request them to include it and take approval before going for admission.
Don’t get confused between day care procedures and outpatient expenses. No Insurance company pays for the stand alone Outpatient treatments like POP because of bone Fracture, stitches with local anesthesia, doctor consultations, health tests etc.,
There are more than 580 Day Care procedures. The number of such Day Care procedures being covered differs from insurer to insurer.Sample List can be found here.
Only 24 hours inpatient Hospital admission is not enough. There should be an inline treatment as well.
For example, if I get chest pain at night and I go to emergency hospitalization thinking that it might be a heart attack. Doctor got me admitted and did a series of Health tests and later from those tests it was found that the chest pain was due to the gastric problem and no treatment was administered. I will be happy that nothing happened to me, but I will be disappointed that my claim for the admission and health tests will get rejected as there was no inline treatment. But in case the doctor finds some issue with my health and gives me some treatment, then the hospitalization bill along with those health tests and medicines gets covered.
During certain cases when the patient’s condition is not such that he can be moved to Hospital, Insurers agree to consider the claim and reimburse the expenses under the Domiciliary hospitalization cover. However you need to check if your policy has such cover.
Apart from room rent all the other items as listed above under hospitalization expenses are dependent on how the room rent is being charged at the hospital. This feature has a great impact on the overall claim amount payable under health insurance.
Insurance companies put a sub-limit (Capping) on the room rent payable under health insurance policy in case of hospitalization.
If you opt for a room rent crossing the limit mentioned in the policy, along with excess rent, the insurance company will deduct the cost of other services like doctor’s fees, surgery charges, etc. proportionate to the room rent charges.
This is because, in any hospital, the cost of exactly the same set of services is charged differently for different room types. The hospitals charge low cost for rooms with lower rent and high cost for the room with higher rent.
Charges which are based on MRP (like medicines) are charged the same for all types of rooms. Hence, these charges will have no impact on room rent capping.
Let’s understand this better with an example:
Hence, it’s always advisable to select your health insurance policy wisely by verifying room rent you are eligible to opt. It is good to have no capping on room rent to feel free to select the room as per availability and rent charges in the hospital.
Any Disease or condition which exists prior to taking the first policy with an Insurance company is called a pre-Existing disease.
No Insurance Company covers the pre-existing diseases from day 1 ( Except in group health insurance)
All the pre existing diseases “ Whether it is known or not known” gets covered after a certain waiting period like 24,36 or 48 months depending upon the insurer.
We should declare (If we are aware) of all the existing conditions, Symptoms, Disease or treatment taken in the last 48 months in the proposal form at the time of taking the policy.
The Insurance Company will then decide whether to give the Health Insurance cover or not depending on
Insurance underwriters sometimes decide to accept the proposal, by Loading certain additional premiums or by doing a health check up.
If we don’t declare any disease and if a claim occurs and the insurance company finds that the insured did not declare the disease even if he was aware of it, then they will reject the claim and cancel the policy without refunding the premium. They do so under the clause “Mis-Representation of fact”
If we do not have any pre-existing issues of any kind, and are completely healthy, then we need not bother about which company is providing a shorter waiting period for this coverage. Because such ailments are covered if they occurred for the first time after 1st month of the policy inception.
Nowadays there are specific policies being issued by insurers for certain pre-existing conditions like, diabetes, cancer, cardiac, obesity etc. Where the coverage is designed as per their health conditions. There is a waiting period in these policies too, but it’s just 12 months to cover the expenses related to such specific ailment.
This is one of the most dreadful clauses in Health Insurance.
The terms “reasonable, usual and customary” refer to the average claim paid by your Insurance Company for a particular ailment. A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company. The insurance company then uses this information to determine how much it’s willing to pay for a given service in your area. This means that if your hospital charges above the reasonable and customary charge, you may have to pay the remainder.
This clause gives a lot of room for an insurance company to cut down the claim amount and in fact it is the most disputable clause of the whole policy document.
We at Ethika helps you choose the right insurer which will help you not to get such surprises at the time of Claim.
If the Sum Insured is enhanced during this waiting period, then the waiting period applies fresh to the amount of sum insured extended.
The respective waiting periods are specified as below.
30 Days waiting period: Any hospitalization except due to an accident is not covered for the first 30 days of policy inception. This waiting period is applicable only for the first policy year. Upon continuous coverage for the upcoming years, this waiting period is waived off. This will be again applicable only in 2 conditions:
2 years waiting period: The below listed diseases are covered only when there is a continuous coverage of 2 years and occurs for the first time after the issuance of policy.. In case it is a pre-existing issue, then it will be covered after the completion of the waiting period specified for pre-existing conditions. A sample list of diseases where this waiting period is applicable is listed here
Pre-Existing Waiting Period: Usually there is a waiting period of 48 months to cover a pre-existing issue. Few insurers have reduced this to 3 years as well. Few also provide a rider option to reduce the waiting period to 2 years.
Maternity Waiting Period: The waiting period for maternity claim varies from 2 to 6 years in various plans available in the market. There are a couple of plans which provide a 9 months waiting period for maternity but the premium is so high that it is as good as creating a reserve from our own funds.
New Born Cover Waiting Period: There is a waiting period of 90 days to cover the newborn. However Many insurers cover a new born baby from day 1 within the maternity limit or overall sum insured limit.
Waiting period is the time during which claim is not admissible although you have a policy in force.
Hospitalization is not always an emergency situation. Depending on the ailment you can have sometime in hand to decide when to get admitted.This clause is to avoid any moral hazard of people buying health insurance once they already suffer with any ailment and needs hospitalization. Hence there are specific waiting periods specified for certain illnesses.Most of such illnesses are very certain at a particular age. The other benefit of waiting periods is that the insurer will have a couple of premiums at least from the insured to bear the expenses when claimed.
If the Sum Insured is enhanced during this waiting period, then the waiting period applies fresh to the amount of sum insured extended.
The respective waiting periods are specified as below.
30 Days waiting period: Any hospitalization except due to an accident is not covered for the first 30 days of policy inception. This waiting period is applicable only for the first policy year. Upon continuous coverage for the upcoming years, this waiting period is waived off. This will be again applicable only in 2 conditions:
2 years waiting period: The below listed diseases are covered only when there is a continuous coverage of 2 years and occurs for the first time after the issuance of policy.. In case it is a pre-existing issue, then it will be covered after the completion of the waiting period specified for pre-existing conditions. A sample list of diseases where this waiting period is applicable is listed here
Pre-Existing Waiting Period: Usually there is a waiting period of 48 months to cover a pre-existing issue. Few insurers have reduced this to 3 years as well. Few also provide a rider option to reduce the waiting period to 2 years.
Maternity Waiting Period: The waiting period for maternity claim varies from 2 to 6 years in various plans available in the market. There are a couple of plans which provide a 9 months waiting period for maternity but the premium is so high that it is as good as creating a reserve from our own funds.
New Born Cover Waiting Period: There is a waiting period of 90 days to cover the newborn. However Many insurers cover a new born baby from day 1 within the maternity limit or overall sum insured limit.
If the sum insured is exhausted during a claim, then the sum insured is restored to full amount which can be used for future claims within the policy year not related to the same ailment for which the first claim was made.
There are 2 drawbacks of this feature.
Hence it is good to go for a top up (Super Top up) policy instead of having such an option as a rider (optional benefit upon payment of premium) to avoid such limitations.
Initially only allopathic treatments were covered under health insurance. In 2012, as per a circular from IRDA, Ayush treatments were allowed to be included in health insurance coverage. Currently there are more than 15 insurers providing health insurance cover for Ayush treatment either as an additional rider or as inbuilt cover.
As per IRDA, “AYUSH Treatment” refers to the medical and / or hospitalization treatments given under ‘Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.
The IRDA Definition is simple enough to understand. Lets know its impact.
Impact: Although IRDA has granted permission to cover non-allopathic treatments, there are certain limitations as follows.
Maternity is not an uncertain event like any other ailment. Hence it’s generally excluded from the health insurance cover. However some insurers have special plans in which they provide coverage with a waiting period of 2 or more years and with a cap on maternity expenses within the overall sum insured.
But the good news is, it can get covered under Group Health Insurance with no waiting period.
A Comprehensive Maternity cover provides coverage for both Mother and the new born in different sessions as below.
However, we have to be cautious about the sub-limits under each session. Sometimes the sub-limits under item 2 and 3 above are a part of sub-limit of item 1.
Pre and Post Hospitalization cover is normally excluded for maternity expenses.
There are certain plans which cover maternity expenses with a 9 months waiting period. But the premiums are usually so high that over time, we end up much more than the claimed amount.
In simple terms, if your policy has a co-payment of 20%, then 20% of the admissible claim is supposed to be paid by yourself and the rest 80% is paid by the insurance company.
Deductible acts in a little different way. It says the amount till which the insured is supposed to pay the claim from pocket. Only the amount above the deductible, the Insurer will pay.
For example,
This benefit under the policy covers the medical expenses of the insured person incurred outside India. It is important to understand that global coverage guidelines varies from company to company.
Global coverage limit will be restricted to Sum insured including the cumulative bonus. It will not be extended to recharge or restoration benefit.
Worldwide coverage will be available on a reimbursement basis, few companies also provide the coverage on cashless basis.
The insured also need to check whether the coverage is including or excluding the United states and canada.
Copayment is also applicable sometimes varies from 10 to 20%.
The waiting periods of Pre existing disease, 2 years waiting period will be applicable as usual as per the policy terms.
A Health policy with worldwide coverage or travel policy which one is better? Travel policy comes with additional benefits like Emergency hospitalization, public liability, loss of baggage, passport etc. but pre existing diseases will have the waiting period.
Whereas the worldwide coverage in Health policy, you can get the benefit of coverage of the preexisting diseases or 2 years excluded conditions after completion of the waiting periods. You can also afford to travel to the best countries where the advanced treatments are available in case uncertain conditions. Insurance gives you the privilege of better treatment at a very nominal price.
We also have Health insurance products inbuilt with travel insurance coverage which will be helpful to frequent travelers. It will help the insured to get the benefit of completion of waiting periods.
Outpatient benefit covers the expenses related to physician consultation, Pharmacy bills, Laboratory bills which are done on an outpatient basis. Few companies started providing outpatient services with the limitation upto maximum Rs 5K. Some companies are giving an option to select as additional benefit with limitation based on sum insured with additional premium.
Do not confuse Outpatient benefit with the pre post hospitalization benefit, even though the coverage looks similar but the pre post hospitalization bills are settled based on the inpatient hospitalization or day care procedure.
Outpatient benefit does not bring much value but it could help to some extent but buying this benefit with additional premium is up to one’s family health conditions and usage per year.
The best way to utilize the benefit is to take full advantage of section 80D benefit under income tax.
We are allowed to claim deduction of Rs.25K from our taxable salary for Mediclaim Insurance premium.
But so many of you will be covering yourself (including spouse and kids) within Rs.10K to 15K only.
You can utilise the balance benefit by purchasing a Out patient benefit Insurance policy.
For example, let’s say your Mediclaim premium is Rs.9000. (This is the normal premium you pay for 5 lacs cover for self+spouse+2kids.
You can now buy additional Outpatient expenses insurance policy for Rs.16K. This gives you additional two benefits
Hence the total benefit by paying Rs. Additional 16K premium is Rs.30500
To understand what any insurance policy actually covers, ask your insurance broker or Agent about “What it doesn’t cover”.
Insurance is a pool to cover uncertainties. Hence, exclusions are essential in the policy to avoid claims which are very certain, unlawful, personal comfort, intentional or out of the capacity of insurers to bear the loss. Such permanent exclusions are listed below. However, please go through the policy wordings for any specific exclusions under plan.
Ethika Insurance Broking Pvt. Ltd. IRDAI Certificate No: 574, Date of License: 8th Aug 2019, License valid till 7th Aug 2022, Registered Address: 517, B Block, Vijaya Raghwa Township, Nallagandla Bypass Road, Lingampally. 500019 Principal Officer: Susheel Agarwal, Contact Details of Principal Officer: susheel@ethika.co.in +91 8498094600, Directors: Susheel Agarwal and Suresh Agarwal, Category of License: Direct (Life and General).
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