WHAT OUR CLIENTS SAY

Indemnity based

In this kind of policy, the actual hospitalisation expenses are covered. We can get this reimbursement from the insurer after the claim or we can get it as cashless at the time of claim if the hospital is having tie up with the insurance company.

Benefit based

This policy pays the per day fixed cost calculated by the no of days the insured stays in the hospital for the recovery.
Some policies also pay a lump sum amount in case of any named disease as per policy gets diagnosed. Eg ., Dengu, Cancer, road accidents, etc., These policies are also called critical illness policies.

Our recommendation :

Indemnity based policies are always better as it covers the actual hospitalisation expenses which can go to any extent. Sometimes people misunderstand between these two types of policies and end up buying the benefit based policy as it looks very cheap. Most of the time the benefit based policies are offered by Life Insurance policies. All our discussions here are related to the indemnity based policies.

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 hospitalisation 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.

All the medical expenses like

Room Rent ( Please check the room rent clause), Doctors fees, Intensive Care Unit, Nursing expenses, Surgical fees, operating theatre, anesthesia and oxygen and their administration, Physical therapy expenses, Drugs and medicines consumed on the premises, Hospital miscellaneous (medical costs) services (such as laboratory, x-ray, diagnostic tests), Cost of Dressing, ordinary splints and plaster casts, Costs of prosthetic devices if implanted during a surgical procedure, Organ transplantation including the treatment costs of the donor but excluding the costs of the organ.

Non medical expenses like, TV, Food, Fruits, transport charges, gloves, neeles, cotton, disposable items, tissues, consumables are not covered in any Health Insurance policy.

Some insurers restrict expenses on doctor fees, room rent by a sublimit clauses. Be informed of those limits.

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 room 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 of room rent capping.

Let’s understand this better with an example:

If Room Rent capping in your health insurance policy is Rs 2000/- per day
and the Actual Room Rent you opt for is Rs 4000/- per day

The claim amount is calculated as follows.

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 Insurance company is called a pre-Existing disease.

No Insurance Company covers the pre-existing diseases from day 1.

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

Whether the existing disease is cured or not.

Whether it can occur again later.

Whether it can lead to further ailments whether same or different.

If Insurance underwriter sometimes decides to accept the proposal, by loading certain additional premium.

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 “MisRepresentation of fact”

If we do not have any pre-existing issue of this kind 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.

Any Outpatient cost like Doctor Consultations, medicines, Health tests, taken before or after the Hospitalisation, then those gets covered under Pre-Post Hospitalisation cover.

However the outpatient expenses should be pertaining to the same treatment for which the main medical claim is accepted.

Insurance companies put a cap on these expenses, usually expenses incurred within 30/60 days respectively for pre and post hospitalisation.

For Some expenses like domiciliary, maternity and organ donor, the pre and post hospitalisation cover is not applicable.

Some insurance companies started putting additional caps like 1% of Sum insured on these expenses. Some started disallowing physiotherapy expenses under pre and post hospitalisation.

The cost related to organ donor’s treatment is covered only from the time the donor is admitted to hospital for transplantation surgery, the organ is harvested(removed) and till the time donor is discharged upon recovery.

Such transplantation should be medically advised and approved by law

The policy will not cover

• The cost of Organ
• Any payments for tests or screening for donors to ensure his organ matches the insured and is fit for transplantation.
• Any payments to Govt. Body for getting approval for transplantation.
• Any pre or post hospitalization costs related to donors.
• Any complications arising out of transplantation to the Donor are not payable under recipient insurance nor in Donor’s personal medical insurance.

Not all plans provide similar cover,neither any plan provides complete cover. In some plans its an inbuilt cover whereas sometimes it has to be selected as an special benefit upon payment of additional premium.

The irony is, the donor is not covered fully in recipient’s (Insured’s) policy and his personal medical insurance as well for donating his organ.

Maternity is not an uncertain event like any other ailment. Hence its 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.

1. Normal delivery or C-Section Delivery or Lawful termination of pregnancy : The limits under this session varies from Rs 35000/- to Rs 75000/-.
2. Pre & Post Natal Expenses:
   New Born baby cover: Typically, there will be a waiting period of 90 days to cover a new born baby in health insurance. But we should be prepared if there are any complications immediately after birth. Some companies insure a newborn from day one under the maternity cover as a benefit or additional cover.
3. New born baby 1st year Vaccinations:Few companies also offer to cover vaccination charges but with a sub-limit mostly upto INR 10000.

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 item1.

Pre and Post Hospitalization cover is normally excluded for maternity expenses.

In simple terms, if your policy has a co-payment of 20%, then 20% of the admissible claim is supposed to be paid by insured himself from his pocket and the rest 80% is paid by the insurer.

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,

If Copayment is 20%, then the claim amount payable by the insured is 20% and rest 80% will be paid by the insurer.

If deductible is Rs.25000 rupees, and the claim is around Rs.100000, then the amount paid by the insurer is 75000 only. If the Claim amount is less than the deductible, then no claim is payable by the insurer.

Both copayment and deductible is applied on the final claim (admissible claim) amount and not on the reported claim amount.

The option of co-pay is useful if you already have insurance as a part of group mediclaim from corporate, but with a co-pay, then you can take individual policy with a co-pay option to cover the uncovered part in group mediclaim.

As the name says, No Claim bonus is the benefit which an insured received upon making no claims in previous policy year. Now the question is how this benefit is provided to the insured in health insurance.

The overall Sum Insured will be increased every year without any additional premium. This benefit continues for every claim free year till the Sum Insured is doubled. Hence this is also called a cumulative bonus. It helps us to tackle medical inflation.

This is a standard benefit provided by all the insurers. But the percentage varies. Some insurers provide 10% and some provide 20% for every claim free year.

Some insurers also decrease the Sum Insured by similar Percentage (or all at once) to the earned cumulative Sum Insured till date, upon making a claim.

Nowadays some insurers are providing an optional cover for No Claim Bonus. It has been named differently by different insurers like Super NCB, Multiplier benefit etc.

If you have planned for a Super top up policy as well, then you need not bother about what percentage of Sum Insured is being offered as NCB. However, 10% of NCB is for sure provided for every claim free year. And interestingly NCB is also a part of Super top up policy plans.

Hence instead of paying for optional cumulative bonus rider its advisable to take a super top policy rather than trying to enhance this tentative coverage which would vanish upon a single claim.

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.

1. If the sum insured is not sufficient to pay the first claim itself, restored sum insured is not useful.
2. Most of the insurers will not restore it, if Sum Insured is utilized below 95% of total amount. In this case the insured is again without adequate coverage even if any further contingency occurs.
3. 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.

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.

In case of emergency hospitalization, the ambulance charges are covered up to a certain limit in every health insurance plan.

This is not a parameter on which you decide the health insurance plan as it has least impact on any claim.

Initially only allopathic treatments were covered under health insurance. In 2012, as per a circular from IRDA, Ayush treatments are 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.

1. The treatment has to be done in Govt. Hospital, or in any Institute recognized by Govt. and/or accredited by Quality Council of India or National Accreditation Board on Health. There are more than 3600 such hospitals all over India.
2. Cashless facilities are not available under such treatments.
3. Most of the insurers are applying a capping or sub limit for such treatments.

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 period 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 in 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:

1. i) If there is a break in insurance coverage or policy being renewed with lapsation.
2. ii) The Sum insured is enhanced, the waiting period applies only to the extended sum Insured amount.

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 waiting period specified for pre-existing conditions.

1. All internal and external benign tumors, cysts, polyps of any kind, including benign breast lumps
2. Benign ear, nose, throat disorders
3. Benign prostate hypertrophy
4. Cataract and age related eye ailments
5. Gastric/ Duodenal Ulcer
6. Gout and Rheumatism
7. Hernia of all types
8. Hydrocele
9. Infective Arthritis
10. Piles, Fissures and Fistula in anus
11. Pilonidal sinus, Sinusitis and related disorders
12. Prolapse inter Vertebral Disc and Spinal Diseases unless arising from Accident
13. Skin Disorders
14. Stone in Gall Bladder and Bile duct, excluding malignancy
15. Stones in Urinary system
16. Treatment for Menorrhagia/Fibromyoma, Myoma and Prolapsed uterus
17. Varicose Veins and Varicose Ulcers
18. Renal Failure

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 within the maternity claim from day 1.

The insurance company will have a tie up with hospitals where Hospital will agree for a settlement of bills directly from the insurance company instead of collecting it from the insured. This way an insured can go for a cashless treatment and hence this is called as .Such hospitals are called Network Hospitals.

It is not always a situation of choice but also availability of cashless facilities. But in case we have network hospital in reach,

It is advisable to go for Cashless because

1. It is convenient
2. Some insurers have a negotiated tariff and hence the overall claim amount is reduced.

But the condition is, the insurer must be informed that the insured wishes to avail a cashless facility along with supporting documents.

• 48 hours before the planned treatment
• Within 24 hours after an unplanned hospitalization.

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

1. 30 days waiting period waiver
2. 1/2/3/4 years specific disease waiting period waiver
3. Pre existing waiting period.

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.

You can buy 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 claims assistance and represents the clients to 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.

In a family floater policy the sum insured is floating on all the family members covered under the policy. That means it acts as a pool and any one or more can utilise the sum insured in case of hospitalisation.

It costs less in buying the family floater instead of buying an individual sum insured.

Not only when you are 45, It is difficult to get health cover if you catch any disease, as unfortunately health insurance covers only Healthy people.

Usually after 45 years of age, insurance companies ask for a medical test done before the proposal is accepted. Depending on the test result they decide to give coverage.

If you are already 45, it is always wise to take this pre policy test. It will be difficult for an insurer to avoid the claim if they have accepted the proposal after seeing the test.

No, Insurance companies cannot deny the claim just on the basis of an anticipated claim or claim made last year.

At the most they will stop sending the renewal notice and may expect you to forget paying the renewal premium.

Only two reasons on which they can deny the renewal of cancel the policy in mid term is if they found any misrepresentation of fact in the details given to insurance company or fraud in claim.

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.

Congenital external diseases, mental disorder.

Cosmetic treatments, hair implantation, weight loss treatments.

Dental or plastic surgery unless as a result of an accident

HIV, AIDS or any other sexually transmitted diseases.

Illness caused due to the influence of drugs, alcohol etc.

Injury due to any act performed against the law.

Injury during Participation in adventure Sports .

Naturopathy.

Outpatient expenses.

Hearing aids, spectacles.

Pre existing diseases.