HEALTH INSURANCE / MEDICLAIM POLICIES
What is covered by a health policy ?
What is not covered in a Health Insurance policy ?
PLAN YOUR MEDICAL INSURANCE
No one should have to choose between medicine and other necessities. No one should have to use the emergency room every time a child gets sick. And no one should have to live in constant fear that a medical problem will become a financial crisis.
- Brad Henry
PLAN YOUR HEALTH INSURANCE PRUDENTLY :
MEDICAL INSURANCE - Basics
What is covered under Health Insurance Policy ?
A Medical Insurance Policy would normally cover expenses incurred under the following heads in respect of each insured person subject to overall ceiling of sum insured
a. Room, Boarding expenses
b. Nursing expenses
c. Fees of surgeon, anesthetist, physician, consultants, specialists
d. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radio therapy, cost of pace maker, Artificial limbs, cost or organs and similar expenses.
e. Ambulance charges
Sum Insured
The Sum Insured may have a maximum amount for each of the insured under the policy or cumulative for all the insured or a fixed amount to be paid out on particular type of disease or surgery needed or affixed amount per day for the period of hospitalization.
Pre and post hospitalization expenses
Expenses incurred during a certain number of days prior to hospitalization and post hospitalization expenses for a specified period from the date of discharge may be considered as part of the claim provided the expenses relate to the disease / sickness.
Cashless Facility
Insurance companies have tie-up arrangements with a network of hospitals in the country. If policyholder takes treatment in any of the net work hospitals, there is no need for the insured person to pay hospital bills. The Insurance Company, through its Third Party Administrator (TPA) will arrange direct payment to the Hospital. Expenses beyond sub limits prescribed by the policy or items not covered under the policy have to be settled by the insured direct to the Hospital. The insured can take treatment in a non-listed hospital in which case he has to pay the bills first and then seek reimbursement from Insurance Co. There will be no cashless facility applicable here.
For the list of TPA approved by IRDAI , CLICK HERE
Additional Benefits and other Riders
Insurance companies offer various other benefits like “ Health Checkup “. There are also policies that give benefits like “Hospital Cash”, “Critical Illness Benefits”, “Surgical Expense Benefits” etc. These policies can either be taken separately or in addition to the hospitalization policy. A few companies have come out with products in the nature of Top Up policies to meet the actual expenses over and above the limit available in the basic health policy.
The actual exclusions may vary
FLOATER POLICIES
Family Floater is one single policy that takes care of the hospitalization expenses of entire family. The policy has one single sum insured, which can be utilized by any/all insured persons in any proportion or amount subject to maximum of overall limit of the policy sum insured. Quite. Family floater plans are better than buying separate individual policies all
TAX BENEFIT UNDER SECTION 80D OF INCOME TAX ACT
Deduction allowed on Medicliam Policies under 80 D is Rs. 50,000/- for senior citizens and up to Rs. 25,000/- for others from the financial year 2018-19 . For senior citizens , if no insurance amount is paid , hospital expenditure up to Rs 50,000 is allowed . An assessee can claim additional Rs 50,000 for his / her parents if they are senior citizens and Rs 25,000 in other cases . Overall claim cannot exceed Rs 1,00,000 . All payments should have been made in any mode other than cash . Cost of preventive health check up up to Rs 5,000 can be claimed within the overall limit and it could have been made in cash also .
ISSUERS OF HEALTH COVERS
Mediclaim policies are issued by specialized Health / Medical Insurance companies , Life Insurers as well as General Insurers .
To get the list and visit their websites , Click Here
What is not generally covered in your Health insurance Policy ?
What is not covered in a policy ?
We would have bought medical insurance by paying substantial premium . When we submit our claims , we would be shocked to learn that our claim is rejected or substantially reduced as the policy doesn't cover the illness / treatment we have undergone . Hence we should carefully go through the policy document while / before purchasing an insurance to know what the health insurance covers and what is not covered .
Each policy has its own sets of inclusions and exclusions and we give below some general exclusions which are normally covered in an insurance policy . But carefully study the policy document while purchasing the health insurance .
General Exclusions :
a. All pre-existing diseases . But some policies allow after certain lapse pf period called waiting period which is between 24 to 60 months . Many policies will also not cover the new ailments arising out of pre-existing conditions . Even if they allow , some policies would have limited the cover to certain percentage .
As per IRDAI GUIDELINES ( click here to read the IRDAI CIRCULAR )
Pre-existing Disease means any condition, ailment, injury or disease:
a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement or
b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.
b. Under first year policy, any claim during the first 30 days from date of cover, for sickness / disease. This is not applicable for accidental injury claims.
c. During first year of cover – cataract, Benign prosthetic hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, piles, sinusitis and related disorders. Some policies do not allow treatment for certain diseases like cataract for a period of 24 months to 48 months , even when it was not a pre-existing condition.
d. Circumcision unless for treatment of a disease
e. Cost of specs, contact lenses, hearing aids
f. Dental treatment / surgery unless requiring hospitalization
g. Convalescence, general debility, congenital external defects, V.D., intentional self-injury, use of intoxicating drugs / alcohol, AIDS, Expenses for Diagnosis, X-ray or lab tests not consistent with the disease requiring hospitalization.
h. Treatment relating to pregnancy or child birth including cesarean section
i. Naturopathy treatment.
j. Cosmetic procedure / Fertility treatment
k. Off-label medicines
l. Health issues on account of war , radiations etc .
Further some policy require prior authorization from them before hospitalizations for certain types of ailments .
Hence as a precaution , go through the policy while buying a health policy and follow the procedure / terms & conditions while undergoing a treatment and making a claim . Normally insurance companies offer a free- look period of say 15 days after issue of the policy . If you are not satisfied with the policy terms , you may surrender the policy and look for a fresh policy .
TIPS FOR BUYING MEDICLAIM POLICIES :
1. Various Insurance companies offer health / mediclaim Policies . But the terms , diseases covered and premiums vary . Hence first write down your needs like whether you have parents & children to be covered , Medical history of your family members , and the amount of coverage you require . Please remember the medical costs are increasing year after year and what looks like suffice today may not cover fraction of your requirement after 5 years . Hence keep cushion while having the amount fixed .
2. You check the hospitals in your city , especially which are convenient to you , are covered under cashless facility by TPA .
3. Compare the premiums from three or four insurance companies for the least . and you can find huge variation from company to company and chose the one which suits your budget and requirements .
4. Floaters policies covering all the members of your family are cheaper than taking individual policies and hence get a policy which can cover your family members .
5. Check whether premiums are kept at the same level as offered for at least for few years . Otherwise every year you will have to pay higher demanded premiums .
6. Check up to what your age the policy will cover . There are policies which cover up o maximum age of 80 years . Otherwise at the ripe age when you require insurance , umbrella of insurance would be removed .
7. Check towards the conditions on pre-existing diseases . Lesser period will be better .
8. If you have already covered by a Mediclaim policy taken by yourself or your employer and if you feel the amount covered is not sufficient , you may go in for a Top up Health Insurance or Super top up health insurance which will cover you beyond the amount covered by your initial policy .
9. Health policies get income tax rebates under SEC 80D . For details , CLICK HERE
LATEST GUIDELINES OF IRDAI WHICH OVER-RIDES ALL PREVIOUS CIRCULARS
MASTER CIRCULAR 2024 - HEALTH INSURANCE POLICIES
Dated 30.05.2024 : IRDAI has issued Master circular to insurance companies issuing new guidelines for the issue of health insurance policies and the notification is operative immediately .
The salient features of the guidelines in the circular include
For Policyholders/Prospects/Customers :
1. Wider choice to be provided by the Insurers by making available products/addons/riders by offering diverse insurance products catering to all ages, regions, occupational categories, medical conditions/ treatments, all types of Hospitals and Health Care Providers to suit the affordability of the policyholders/prospects.
2. Customer Information Sheet (CIS) which is provided by the Insurer along with every policy document. It explains the basic features of insurance policies in simple words like type of insurance, sum insured, coverage details, exclusions, sub-limits, deductibles, and waiting periods 3. Customer to be provided with the flexibility to choose products/addons/riders as per his/her medical conditions/specific needs. A Policyholder with multiple health insurance policies gets to choose the policy (s) under which he/she can get the admissible claim amount. The primary insurer with whom claim is first submitted shall coordinate and facilitate settlement of balance amount from the other insurers
4. In case of no claims during the policy period, the insurers may reward the policyholders by providing an option to choose such No Claim Bonus either by increasing the sum insured or discounting the premium amount.
5. Policyholder to get refund of premium/ proportionate premium for unexpired policy period, if he chooses to cancel his/her policy at any time during the policy term
6. A health insurance policy is renewable and shall not be denied on the ground that claim (s) was made in the preceding policy years, except in case of established fraud or non-disclosure or misrepresentation by the Insured. An Insurer shall not resort to fresh underwriting unless there is an increase in sum insured
Some of the important clauses in the master circular are :
HEALTH POLICIES FOR ALL
1. a. Insurers are required to make available products/add-ons/riders to provide wider choice to the policyholders/prospects catering to
i. all ages;
ii. all types of existing medical conditions;
iii. pre-existing diseases and chronic conditions;
iv. all systems of medicine and treatments including Allopathy, AYUSH and other systems of medicine;
v. every situation of treatment including domiciliary hospitalization, outpatient treatment (OPD), Day Care and Homecare treatment;
vi. all regions, all occupational categories, persons with disabilities and any other categories
vii. all types of Hospitals and Health Care Providers to suit the affordability of the policyholders/prospects. Policyholder shall not be denied coverage in case of emergency situations.
HEALTH INSURANCE LATEST TYPES OF TREATMENT
Insurers shall endeavour to cover Technological Advancements and Treatments in their products. Examples of prevalent treatment / procedures that need to be included, and not limited to the following:
a. Uterine Artery Embolization and HIFU
b. Balloon Sinuplasty
c. Deep Brain stimulation
d. Oral chemotherapy
e. Immunotherapy- Monoclonal Antibody to be given as injection
f. Intra vitreal injections
g. Robotic surgeries
h. Stereotactic radio surgeries
i. Bronchial Thermoplasty
j. Vaporisation of the prostrate (Green laser treatment or holmium laser
treatment)
k. IONM - (Intra Operative Neuro Monitoring)
l. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant
for haematological conditions to be covered.
j. Any other treatment using advanced technology, as per the product
design .
Customer Information Sheet (CIS):
CIS is to be provided with every policy in the prescribed format. It is a document provided by the Insurer along with the policy document that explains in simple words, basic features of a policy at one place. The CIS shall
a) be provided to every policyholder in case of both Individual Insurance policy holder as well as a Member of Group Insurance Policy.
b) have details like
i. type of insurance,
ii. sum Insured,
iii. coverage provided,
iv. summary of exclusions which policy does not cover,
v. sub-limits (a pre-defined limit above which insurance company will not pay),
vi. deductibles (specified amount upto which an insurance company will not pay any claim/which will be deducted from total claim, if the claim
amount is more than the specified amount),vii. waiting period(s) (time period during which specified diseases/ treatments are not covered), and
viii. certain important things such as Free Look Period, Policy Renewal,Migration, Portability and Moratorium Period.
c) contain information regarding the Claims Procedure, Policy Servicing and Grievance Redressal Mechanism including contact details of Insurance Ombudsman of appropriate jurisdiction.
Acknowledgment in physical or digital will have to be obtained from the Policyholder. On request, CIS will be made available in local language.
Free Look Period: A period of 30 days (from the date of receipt of the policy document) is available to the policyholder to review the terms and conditions of the policy. If he/she is not satisfied with any of the terms and conditions, he/she has the option to cancel his/her policy. This option is available in case of policies with a term of one year or more.
POLICY CANCELLATION BY THE POLICYHOLDER
The policyholder may cancel his/her policy at any time during the term, by giving 7 days notice in writing. The Insurer shall
a. refund proportionate premium for unexpired policy period, if the term of policy up to one year and there is no claim (s) made during the policy period.
b. refund premium for the unexpired policy period, in respect of policies with term more than 1 year and risk coverage for such policy years has not commenced.
Renewal of Health Insurance Policy
: a. A health insurance policy shall be renewable provided the product is not withdrawn, except in case of established fraud or non-disclosure or misrepresentation by the Insured. If the product is withdrawn, the policyholder shall be provided with suitable options to migrate as per the procedure stated under Chapter II of this circular.
b. An Insurer shall not deny the renewal on the ground that the policyholder had made a claim (s) in the preceding policy years.
c. An Insurer shall not resort to fresh underwriting unless there is an increase in sum insured. In case increase in sum insured is requested by the policyholder, the Insurer may underwrite only to the extent of increased sum insured.
Migration in case of Indemnity policies:
In case of migration of one policy to another with the same Insurer, the policyholder (including all members under family cover and group insurance policies) can transfer the credits gained to the extent of the Sum Insured, No Claim Bonus, Specific Waiting periods, waiting period for pre-existing diseases, Moratorium period etc. in the previous policy to the migrated policy.
Portability in case of Indemnity Policies:
a. A Policyholder has the choice to port his/ her policies from one Insurer to another. The Acquiring and the Existing Insurers shall jointly, ensure that the entire underwriting details and claim history of the Policyholders are seamlessly transferred.
b. The existing insurer shall provide the information sought by the Acquiring insurer immediately but not more than 72 hours of receipt of request through Insurance Information Bureau of India (IIB) https://iib.gov.in/ portal.
c. The Acquiring insurer shall decide and communicate on the proposal immediately but not more than 5 days of receipt of information from
Existing insurer.
d. The policyholder is entitled to transfer the credits gained to the extent of the Sum Insured, No Claim Bonus, specific waiting periods, waiting period for pre-existing disease , Moratorium period etc from the Existing Insurer to the Acquiring Insurer in the previous policy .
Approval for Cashless facility:
a. Every insurer shall strive to achieve 100% cashless claim settlement in a time bound manner. The insurers shall endeavor to ensure that the instances of claims being settled through reimbursement are at bare minimum and only in exceptional circumstances.
b. Insurer shall decide on the request for cashless authorization immediately but not more than one hour of receipt of request. Necessary systems and procedures shall be put in place by the Insurer immediately and not later than 31 st July, 2024.
c. Insurers may arrange for dedicated Help Desks in physical mode at the hospital to deal and assist with the cashless requests. d. Insurers shall also provide pre-authorization to the policyholder through Digital mode.
Final authorization for Discharge from the hospital:
a. Insurer shall grant final authorization within three hours of the receipt of discharge authorization request from the hospital. In no case, the policyholder shall be made to wait to be discharged from the Hospital
b. If there is any delay beyond three hours, the additional amount if any charged by the hospital shall be borne by the insurer from shareholder’s fund.
c. In the event of the death of the policyholder during the treatment, the insurer shall: i. immediately process the request for claim settlement.
ii. get the mortal remains (dead body) released from the hospital immediately .
Claims in respect of multiple Policies held by policyholders:
a) Indemnity Policies: A policyholder can file for claim settlement as per his/her choice under any policy. The Insurer of that chosen policy shall be treated as the primary Insurer. In case the available coverage under the said policy is less than the admissible claim amount, the primary Insurer shall seek the details of other available policies of the policyholder and shall coordinate with other Insurers to ensure settlement of the balance amount as per the policy conditions, without causing any hassles to the policyholder.
b) Benefit based Policies:
On occurrence of the insured event, the policyholders can claim from all Insurers under all policies.
To read the master circular of IRDAI dated 29.05.2024 , CLICK HERE
CASHLESS EVERYWHERE SCHEME :
TERMS & CONDITIONS FOR EXTENDING " CASHLESS EVERYWHERE " SCHEME :
UPDATE DATED 28.06.2024 : Now the cashless everywhere scheme has already been launched by many insurance companies like National Insurance Company , United India Insurance company , Reliance General insurance company , HDFC Ergo Insurance company , ICICI Lombard , Bajaj Allianz , Tata AIG etc . You may check with your insurance company / TPA for any clarifications .
Dated 28.01.2024 : In order to ease the burden of policyholders who get treated in a hospital not in the network of the Insurance Company, the General Insurance Council, in consultation with all the General and Health Insurance Companies, is launching the “Cashless Everywhere” initiative. Under Cashless Everywhere, the policyholder can get treated in any hospital they choose, and a cashless facility will be available even if such a hospital is not in the network of the Insurance Company. For availing the facility , the policyholders have to comply with the following terms & conditions generally :
1. For Planned Admission, the assigned TPA should receive the Intimation about the Planned Admission at least 48 hours prior to the proposed date of admission. The Intimation should be sent by email to the TPA mentioned in your policy.
2. For Emergency Admission, the assigned TPA should receive the Request for Cashless Facility in the Prescribed Form at least within 48 hours after the time of admission.
3. The Hospital where the treatment is to be taken should meet the requirements of the Policy T & C as well as the insurance Company’s internal guidelines.
4. Cashless Facility would be available only if the treatment is found admissible under the terms of the Policy.
5. The Request for Cashless Facility (in the Prescribed format) should be completed and signed by the Insured Person and the Hospital and submitted with all the requisite documents including a copy of the Insured Person’s Identification.
6. The Request for Cashless Facility should be sent to TPA by email as mentioned in the policy.
7. Hospitals which are not in the Company’s Network should provide the Letter of Consent to extend Cashless Facility.
8. Insurance Companies reserves the right to reject the request for Cashless Facility. If Cashless facility is denied, the Customer may submit the papers for claiming under reimbursement basis on completion of the treatment, and admissibility of the claim would be subject to the terms of the Policy.
9. In case of any query , one may contact the TPA mentioned in the policy.
10 . Any other condition may be stipulated by a specific insurance company
PREMIUMS FOR HEALTH INSURANCE POLICIES : COMPARE BEFORE BUYING
To buy a Health insurance policy , you have to pay a fee called premium to the insurance company affront . Now IRDAI has allowed the monthly / quarterly / half yearly payment on the policies . Each insurance policy carries its own premium to be paid for a person of particular age . As each insurance policy was differing in coverage / inclusions / exclusions / co-pay / pre-existing diseases coverage / waiting period etc , it was difficult to compare the premiums of two policies even when the covered amount is same .
To mitigate the problem , Insurance Regulatory & Development Authority of India ( IRDAI ) has come up with standard policies to be mandatorily issued by all general and health insurance companies that deal in Health insurance . While terms & conditions will be same , premiums can differ .
When you compare , you will come to know the actual variation in premium of each policy issued by various insurers . Hence it is prudent for you to get quotes from as many as possible companies before deciding on a insurance policy . Otherwise you will end up with paying a huge premium .
HAVE YOU SUBMITTED A REIMBURSEMENT CLAIM FROM A TPA ?
Dated 31.05.2024 : Are you made to run from pillar to post to get additional documents after you submit a reimbursement claim on your health policy from a TPA ? Then you submit the documents and TPA is not satisfied with the documents you have collected and claim settlement delayed ?
Now it's the responsibility of TPA to collect all necessary papers / documents from the hospitals , once you have submitted the claim . Now they are not supposed to call for additional papers from the policy holders Now Policyholders will not be required to submit the documents., as per the new master circular of IRDAI .
If you have multiple health policies , you can make a claim as per your choice under any policy. The Insurer of that chosen policy shall be treated as the primary Insurer. In case the available coverage under the said policy is less than the admissible claim amount, the primary Insurer shall seek the details of other available policies of the policyholder and shall coordinate with other Insurers to ensure settlement of the balance amount as per the policy conditions, without causing any hassles to the policyholder.
Other salient features of the guidelines in the circular include
1. Health policies for all , to cover all types of treatment
2. Insurer shall decide on the request for cashless authorization immediately but not more than one hour of receipt of request.
3. Insurer shall grant final authorization within three hours of the receipt of discharge authorization request from the hospital.