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Do you know the most common exclusions in a mediclaim plan?
Or, why your base premium keeps increasing over a period of time?
Sanjib Jha, CEO, Coverfox Insurance Broking (external link), answers five most frequently asked questions about health insurance.
He also answers your health insurance related queries.
Please mail your queries to getahead@rediff.co.in with the subject line 'Ask Sanjib' and he will answer all your health insurance queries.
1. What all is covered in a comprehensive health insurance policy?
Health insurance is a safety net for the financial well-being of an individual or a family. With medical inflation close to 15 per cent year on year, it has become imperative to opt for a comprehensive health insurance plan for the entire family so that the hospitalisation expenses are taken care of.
A comprehensive health insurance plan is an indemnity plan and hence pays for all expenses incurred during hospitalisation. It typically covers all hospitalisation expenses related to an illness, injury or an accident.
So, from the time of hospitalisation, the cost of an ambulance, room rent, medicines, diagnostic tests, surgery/ implant or any other treatment procedures, etc. would be covered under in-patient hospitalisation. Additionally, pre- and post-hospitalisation expenses for diagnosis and follow up treatments, AYUSH treatment, domiciliary, organ donation, etc. treatments and procedures are usually included.
There are other value-added benefits of comprehensive health insurance plans as well; such as free annual medical check-ups, sum insured restoration benefits, maternity and other covers. You can further enhance the base coverage by purchasing optional add-ons like personal accident and critical illness coverage.
2. Would my base premium remain constant, or it would change over a period?
Yes, your premiums would increase over time and it depends on age brackets, claim experience and other factors. So, even if you opt for a health insurance plan earlier in life, your premium would go up almost every year or every 5 years, depending on your age, health conditions and other factors.
So, the natural question everyone would have is, why opt for a health insurance plan early? In any case, younger people need to claim their health insurance lesser than older people, right? So, should the younger ones wait to grow old before opting for a good HI plan?
In my opinion, the answer is NO and there are multiple reasons for the same.
a. Is there a guarantee that the young will not fall ill?
With COVID-19 second wave, we have seen that the young needed more hospitalisation than the old.
b. With the rise of lifestyle ailments, diabetes, obesity, digestive concerns and hypertension has taken a leap in the youth of India. Fitness and a healthy lifestyle, which have taken a backseat, need to be focused along with a large comprehensive health plan to tackle the issue.
c. The earlier you opt for a health insurance plan, the lesser likely it would be that you would have any pre-existing ailments. So, your coverage quantum would be higher than if you have any of the pre-existing lifestyle ailments.
d. Since the young usually need lesser hospitalisation than the old, your mandatory and specific waiting periods would be over before you actually need them.
The moral of the story is that you need to opt for a high health insurance plan as early as possible. You can always top it up later.
3. If I have a chronic ailment (diabetes, BP, thyroid, heart condition, etc.) can I still get coverage? Should I inform the insurer?
Yes. If you have any major health ailments in India -- whether it's Thyroid, BP or Diabetes -- you can still avail of your hospital and medical expenses. There are policies available for patients with the common complications of prevalent conditions like diabetes and thyroid. There is health insurance coverage accessible for everyone, but make sure you notify your insurance provider of any illnesses and understand your policy's coverage.
Thus, when you fill up your proposal form for a health insurance plan, you need to disclose all material facts; else your claim might be rejected on the basis of non-disclosure or misrepresentation of material facts. So, if you have high blood pressure or diabetes, just remember to mention it along with the list of medications prescribed to you. Then, the underwriter will assess your risk and quote the premium accordingly. Also, there could be a waiting period, or, an exclusion attached.
Once the health insurance plan is accepted with the specified risks, all expenses associated with your pre-existing ailment would be covered by your insurer.
4. What are the most common exclusions in a health plan?
Certain conditions are not covered by health insurance policies. These conditions will land in an ‘Exclusion' in your health insurance policy.
The exclusion list includes unless specifically mentioned in your policy document:
1. Pre-existing health conditions which are not declared from the time of policy inception
2. Lifestyle-related conditions
3. Maternity related complications, including treatments and childbirth, etc,
4. Cosmetic Treatments unless necessary for survival
5. Suicide Attempt Injuries
6. Congenital Diseases
7. War Injuries
8. Dental and eye expenses, unless specifically covered under OPD
9. Diagnostic tests without any proper line of treatment which needs hospitalisation
10. Therapies such as naturopathy, magnetic or acupressure, etc.
11. Waiting Period Illnesses
The insurance provider will not accept any claims in these instances. However, you can purchase add-on coverage to include any exclusion to your base coverage.
5. I have a corporate policy do I still need personal insurance?
Yes. Personal plan is a great alternative to corporate policies -- even if you work for large companies. Corporate policies come with limited coverage with limited or no option to customise it. In fact, your coverage can even decrease over time.
Plus, there's no lifelong renewability once you exit the group. Thus, when you actually need the plan, that is, in your post-retirement phase, you would have to opt for limited coverage available in senior citizen plans.
Also, individual health insurance plans give the flexibility to choose the right kind of protection and better coverage. You can customise your policy, such as selecting the cover according to your needs. It ensures lifelong renewability and additional coverage options, such as hospital cash benefits, pre-existing conditions coverage, etc.
Proper health insurance planning includes high coverage of personal health insurance plans with lifelong renewability over and above group plans!