Health Insurance in India

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Health insurance can be defined as insurance against the future medical expenditure of a person. This means that when someone takes a health insurance plan he or she expects a certain amount of medical expense to be there in future and that individual is paying for that in the present in the form of premium. The main aim of a health insurance plan is to make sure that people have enough money to take care of their emergency medical requirements when they get old.

However, a health insurance policy does not always cover every possible health problem someone might encounter in the future. There are certain terms and conditions agreed to by the insured (person who is taking the plan), and the insurer (entity that is providing the plan) and the entire procedure happens according to what has been agreed to in the contract.

Appropriate time to take health insurance

According to experts the best time to avail a health insurance plan is when the insured is still in a good physical condition. The normal logic among young people is that since they are rarely afflicted by physical ailments they do not need such a plan.

In reality people can fall prey to a disease or other physical problem at any time - nobody can be absolutely sure of a life fully free of such issues. Normally as someone gets older the problems increase and the possibilities of some major disease are always there.

A problem with trying to get a medical insurance during old age is that since there are more chances of a medical condition the premium is often high or the insurer is not ready to cover the individual in question.

Types of Health Insurance

In India there are two major types of health insurance plans - critical illness insurance and medical insurance.

Medical insurance: this form of insurance provides hospitalization cover and pays back medical costs that have been there for paying for diseases or surgery when the insured was admitted in a healthcare facility.

Following are the various forms of medical insurance:

  • Individual medical insurance
  • Overseas medical insurance
  • Group medical insurance

There are certain health policies which pay back the actual expenses of hospitalization for all diseases - these programs are primarily offered by non life insurance providers and are normally referred to as Mediclaim policies. The other health insurance policies are available from both non life and life insurers.

The accidental insurance policies insure a person against the risk of any form of accident. There are certain health insurance providers such as Apollo Munich who provide medical accident insurance facilities as well. Besides, there are several other insurance providers that have accidental insurance policies:

  • Royal Sundaram
  • HDFC Ergo
  • ICICI Lombard

Critical illness insurance: this type of health insurance provides cover against the threat of major ailments. With this program, the insured can be sure that he or she will be receiving a pre determined amount in case the individual is diagnosed with a critical illness that is part of the initial agreement.

With these plans, the payment is done within a few days of the diagnosis and once the payment is done the policy is no longer in operation. Under normal circumstances these plans cover the following:

  • Aorta graft surgery
  • Significant organ transplant
  • Cancer
  • Multiple sclerosis
  • Coronary artery bypass surgery
  • Paralysis
  • First heart attack
  • Primary pulmonary arterial hypertension
  • Kidney failure
  • Stroke

Ways to file health insurance claims

The following documents are needed in order to register the claims for a health insurance policy:

  • Properly filled and signed claim form
  • Reports and receipts of diagnostic tests accompanied by doctor's notes
  • Discharge certificate of the hospital
  • Receipts and bills from consultants, anesthetists, or specialists with diagnosis certificate
  • Illness related documents right from the day it was detected - this includes consultations with the physician and the insured's medical history and
  • reports
  • Surgeon or doctor's certificate that states the complete recovery of the insured
  • Bills, cash memos, and receipts from the healthcare facility - this needs to be backed up with proper prescriptions
  • Providing previous policies' details to the third party administrator - accidents are regarded as exceptions
If the hospitalization is planned the following procedures need to be followed:

Getting in touch with the 3rd party administrator for the particular policy and providing them the information about hospitalization Making sure that the healthcare facility is in the network - even if the hospital or nursing home is not in the network the money will be provided Verification of coverage terms

Contacting the TPA (third party administrator) regarding the availability of cash less facility

If the hospitalization is not planned the processes mentioned below have to be adhered to:

  • The TPA has to be informed as early as possible and the claim form has to be collected and filled up properly
  • The claim form along with necessary documents has to be submitted within 7 days of the insured's recovery
  • Procure all the treatment related documents from the hospital once treatment is completed
  • Bills have to be paid by the insured initially - the insurance company will only reimburse them
  • The policy document has to be read properly to understand which expenses are included

There is a possibility that the claimant may be rejected if the disease is not covered by the plan. In such circumstances the claimant needs to send a letter to the organization within 15 days to file a complaint.

If the payment is incomplete the claimant needs to contact the TPA and find out the reasons for the same. In majority of such cases it has been seen that if additional papers are provided the remainder of the claim is settled.

Benefits of Health Insurance Policy

The major advantages of a health insurance policy may be enumerated as below:

  • Assists in securing the future through premiums
  • Payment for medical and hospitalization bills
  • Saves lot of future financial losses due to costly medical and post treatment expenses
  • Custodial and disability bills
  • Heightened sense of security
  • Tax benefits as per Indian Income Tax Act's Section 80D
  • Greater financial security
  • These policies can even be availed after crossing 60 years

How to Choose a Health Insurance Policy

There are different ways to judge the viability of an insurance policy but the most basic ones may be mentioned below:
  • Comparison of features and prices before availing a policy is essential. Aggregator sites can be used for this purpose
  • In case of brokers it is advisable to get their license numbers and verify the details from the IRDA website. Since the brokers operate independently they will offer the best advice instead of preferring a particular company as is done by the agents
  • In case of families it is better to avail a family floater policy, which is less costly and provides better coverage for every family member. It also enables a family member to use any part of the policy - this facility comes in handy as the instances of an entire family falling sick are rare
  • It is better to provide complete and true information in the declaration form. This will ensure proper payment of claims Thorough comparison of policy terms - brokers normally provide the best suggestions in this regard
  • It is better to eat healthy and work out consistently. Smoking and drinking should be avoided totally as well. These will make sure that the premium comes down in time
  • It is better to avoid a policy that has cashless arrangements with a nearby hospital or nursing home. It is advisable to go for a policy that provides adequate fulfillment of requirements
  • If an insured has a disease already it is better to take utmost care and not think about the insurance while deciding on lifestyle and habits. This will be beneficial in the long term
  • Do detailed research on the hospitals covered by a particular plan and determine their respective areas of specialty. This will help in taking quick decisions at times of emergency

Parameters of a Good Medical Insurance Policy

A health insurance policy should have the following criteria to be regarded as a viable option:
  • Should pay for fees of hospital rooms, surgeons, and doctors
  • Should provide basic protection
  • Should pay for medicines, medical tests, and relevant expenses
  • There should be extra options that can be availed later on as per the needs of the insured
  • The specific health plans should include crucial ailments like kidney failure and heart attack or cancer and diabetes
  • The critical illness plans should provide tax benefits
Health Insurance Premium

Following are the factors that are considered significant in determining a health insurance policy's premium:

  • Age - the older the insured, the higher the premium
  • Policy terms - if the term period is higher the premium will come down
  • Earlier medical history - if the insured does not have a disease already premium will be lower
  • Claim free years - the more claim free years a person has the lower the premium will be
  • Work atmosphere of insured - pilots and miners need to pay more than teachers or clerks. The logic is that in occupations perceived as more hazardous there are greater chances that the insured will encounter health problems
Coinsurance: As per this arrangement, a certain percentage of insurance will be paid by the company. This has a direct effect on the premium

Copay: This benefit is provided in case of individual health insurance plans. Hereby, insurance providers share the medical expenses like fees for doctor and medicine charges.

Top Health Insurance Companies in India

Following are the some of the leading health insurance providers of India and the best policies provided by them:

CompanyTop Policies
Star Health & Allied Insurance Company Limited
  • Senior Citizen Red Carpet
  • Star Family Health Optima
Bajaj Allianz General Insurance
  • Health Guard
Max Bupa Health Insurance
  • Heart Beat Gold
  • Heart Beat Platinum
  • Heart Beat Silver
Oriental Insurance
  • Happy Family Floater
Apollo Munich
  • Easy Health Gold
  • Easy Health Exclusive
  • Easy Health Standard
  • Easy Health Premium
United India Insurance
  • Family Medicare
Reliance Health Insurance
  • Health Wise Family Floater
New India Assurance
  • Mediclaim Policy
ICICI Lombard
  • Health Advantage
National Assurance
  • Varishta Mediclaim