Exclusions:
They vary from insurer to insurer. Before you buy a health cover, make sure that you go through the list of exclusions (illnesses and associated expenses) that are not covered under the plan. For example, most policies do not cover treatments pertaining to piles, cataract and so on in the first year. Also, a large number of policies do not entertain claims for pregnancy-related expenses and dental treatments. However, some insurers have started selling policies that cover such expenses as well. This apart, the cost of diagnostic tests, preventive care, vitamins and tonics, external aids like pacemakers and wheel-chairs are usually not covered. However, if the insured has to undergo medical tests in connection with an upcoming surgery, such costs and also those pertaining to related medicines taken during the period, will be reimbursed as part of pre-hospitalisation expenses. A majority of health policies cover expenses up to 30 days prior to hospitalisation and 60 days after discharge.
Past Baggage:
Most policies cover expenses incurred for the treatment of pre-existing diseases only after a waiting period. Pre-existing diseases are defined as those which were diagnosed or treated during the 48 months prior to taking the policy. However, if your illness is not chronic in nature, or it has not persisted after you received the treatment, there is no cause for concern. For instance, if you had undergone an appendicitis surgery, it will not be treated as a pre-existing illness. Also, usually, health covers kick in only after 30 days of buying them, except in cases of accidents.
Waiting Period:
This is applicable to pre-existing diseases which are not admissible. It can vary from one to four years, depending on the policy and the insurance company. This assumes significance, particularly, if you decide to switch insurers, as the new insurance company may insist on you serving the waiting period all over again.
Restrictions:
It is important to know the illnesses that are not covered by your policy. But it is equally important to know how much you can spend on them. Most policies cap room rent and operation theatre charges, even if the total claim does not exceed the limit. Contrary to what many policyholders believe, the ceiling is not restricted to the room rent alone. While disbursing the claim, all other charges too are proportionately reduced, as the tariffs for treatments usually vary as per the type of rooms. Similarly, if you have signed up for a policy with a co-payment clause, you will be required to share the part of the claim in the pre-agreed ratio, which could range from 10-25% of the eligible claim. On the positive side, policies with co-payment options also bring down the premiums. Higher the ratio, lower will be the premium.
Reasonable & Necessary:
You should also be aware of the implications of the reasonability clause which declares that only the 'reasonably and necessarily' incurred expenses will be admissible as part of the claim. So, if you have been charged, say Rs 50,000, for a treatment procedure that generally costs Rs 40,000, the insurer will approve the claim to the extent of the lower amount.
Claiming The Money:
This is applicable mainly to reimbursement claims. In the case of cashless facility, the approval is instantaneous. To ensure that your claim is entertained, ensure that you intimate the TPA/insurer within seven days of hospitalisation and submit the relevant documents within 15 days from the date of discharge. A failure on your part to adhere to the deadline could result in the rejection of your claim.
Renewal Guarantee:
Irda has stipulated that health insurance companies cannot reject policy renewal requests on the ground that a claim was made in the earlier years. It can be turned down only in cases of fraud, moral hazard or misrepresentation. The policy's prospectus has to contain detailed information on terms of renewal, specific circumstances where the premium could be loaded as well as the extent to which it would be done. One should go through the documents carefully and opt for a policy where the terms and conditions provide a definite picture of any loading on future premiums.
They vary from insurer to insurer. Before you buy a health cover, make sure that you go through the list of exclusions (illnesses and associated expenses) that are not covered under the plan. For example, most policies do not cover treatments pertaining to piles, cataract and so on in the first year. Also, a large number of policies do not entertain claims for pregnancy-related expenses and dental treatments. However, some insurers have started selling policies that cover such expenses as well. This apart, the cost of diagnostic tests, preventive care, vitamins and tonics, external aids like pacemakers and wheel-chairs are usually not covered. However, if the insured has to undergo medical tests in connection with an upcoming surgery, such costs and also those pertaining to related medicines taken during the period, will be reimbursed as part of pre-hospitalisation expenses. A majority of health policies cover expenses up to 30 days prior to hospitalisation and 60 days after discharge.
Past Baggage:
Most policies cover expenses incurred for the treatment of pre-existing diseases only after a waiting period. Pre-existing diseases are defined as those which were diagnosed or treated during the 48 months prior to taking the policy. However, if your illness is not chronic in nature, or it has not persisted after you received the treatment, there is no cause for concern. For instance, if you had undergone an appendicitis surgery, it will not be treated as a pre-existing illness. Also, usually, health covers kick in only after 30 days of buying them, except in cases of accidents.
Waiting Period:
This is applicable to pre-existing diseases which are not admissible. It can vary from one to four years, depending on the policy and the insurance company. This assumes significance, particularly, if you decide to switch insurers, as the new insurance company may insist on you serving the waiting period all over again.
Restrictions:
It is important to know the illnesses that are not covered by your policy. But it is equally important to know how much you can spend on them. Most policies cap room rent and operation theatre charges, even if the total claim does not exceed the limit. Contrary to what many policyholders believe, the ceiling is not restricted to the room rent alone. While disbursing the claim, all other charges too are proportionately reduced, as the tariffs for treatments usually vary as per the type of rooms. Similarly, if you have signed up for a policy with a co-payment clause, you will be required to share the part of the claim in the pre-agreed ratio, which could range from 10-25% of the eligible claim. On the positive side, policies with co-payment options also bring down the premiums. Higher the ratio, lower will be the premium.
Reasonable & Necessary:
You should also be aware of the implications of the reasonability clause which declares that only the 'reasonably and necessarily' incurred expenses will be admissible as part of the claim. So, if you have been charged, say Rs 50,000, for a treatment procedure that generally costs Rs 40,000, the insurer will approve the claim to the extent of the lower amount.
Claiming The Money:
This is applicable mainly to reimbursement claims. In the case of cashless facility, the approval is instantaneous. To ensure that your claim is entertained, ensure that you intimate the TPA/insurer within seven days of hospitalisation and submit the relevant documents within 15 days from the date of discharge. A failure on your part to adhere to the deadline could result in the rejection of your claim.
Renewal Guarantee:
Irda has stipulated that health insurance companies cannot reject policy renewal requests on the ground that a claim was made in the earlier years. It can be turned down only in cases of fraud, moral hazard or misrepresentation. The policy's prospectus has to contain detailed information on terms of renewal, specific circumstances where the premium could be loaded as well as the extent to which it would be done. One should go through the documents carefully and opt for a policy where the terms and conditions provide a definite picture of any loading on future premiums.
