In India higher spending on health care is one of the major factors pushing people into poverty. About 3.5% of the population falls below the poverty line and 5% households suffer catastrophic health expenditure due to unaffordable health cost. It is the people belonging to the lower income classes or poor who suffer the most. The financial burden due to health care expenditure is a major issue we are facing in India. Day by day health care cost is increasing both for out-patient and in-patient treatment. Hence health insurance is emerging as an alternative for reducing the financial burden of the people.
In-patient hospitalization - Covers hospitalization expenses due to an illness or accident for a minimum period of 24 hrs. Generally pays for medical expenses incurred for room rent, surgeon’s fees, nursing expenses, Anesthetist’s fees, intensive care unit, medical practitioner, medicines or drugs ,Emergency ambulance and other related expenses.
Pre & Post Hospitalization - Pays for medical expenses incurred up to 30 days /60 days due to an illness immediately before hospitalization; Post hospitalization pays for medical expenses incurred immediately after the discharge from hospitalization (This coverage shall be claimed for same ailments /Disease ,the coverage days is different from company to company )
Non Allopathic Treatments – Pays for medical expenses for in-patient treatment taken under Ayurveda,Unani, Sidha or Homeopathy in the Government hospitals or Government approved hospitals .
Domiciliary Treatment - Pays for expenses incurred for medical treatment taken at home, on the advice of a physician there are few conditions like the minimum period of treatment in home should be 3 days etc., The coverage is different from company to company.
Day care procedures - Pays for medical expenses for day care treatments which do not require 24 hours hospitalization due to technological advancement.
Hospital Cash /Convalescence Benefit –Certain amount will be paid to the claimant in addition to the hospital expense for each completed day of hospitalization (There is a minimum and maximum required period of hospitalization under this cover generally 3 days for minimum and 10 days for maximum); Under convalescence benefit a lump sum amount will be offered to the insured for each policy year if the hospitalization exceeds a certain period for eg., continuous 10 days.
FAQ’s
Why should I take a medical insurance plan?
The Medi-claim plans helps you at the time of emergency hospitalization due to accidents or any other illness ,the insurance company will indemnify the actual losses up to the maximum of the sum insurance, Please go through the policy document before you purchase .In general per say “It either helps you in protecting your savings /limit your liability “.
What is Family floater cover?
Family floater is the umbrella coverage for entire family, the single policy shall be taken and renewed for a family (generally family means Husband + Wife+2 children’s the children’s age should be less than 25 years).One sum insurance shall be used for the entire family based on the hospital requirements .
What should I do if there is a hospitalization?
Carry your Health card /Policy document at the time of hospitalization and inform the insurance desk or the hospital authorities about your policy and check with them on cashless tie up with the insurance company or TPA(Third party administrator) if yes we can proceed for cash less treatment .If the hospital don’t have tie up then you need to inform the insurance company within 7 days from the date of discharge and please collect all original bills with seal and sign ,Doctors prescriptions, Discharge certificate or summary and submit the documents and duly filled claim form to the insurance company .
What do we mean by Regain or Restoration and Top up plans ?
Regain or Restoration under this cover the policy sum insurance upon exhaustion shall automatically restored once by 100% for the remaining period of policy .Such restored sum insurance can be utilized only for the illness/disease unrelated for which claims were made.
About Top Up Cover :-
What do you do when you want to take a very high health insurance cover like 25 lacs? Is the only option a regular health insurance plan? In this case, you can use top up health insurance plans, which is the best ways to enhance your health cover after a certain threshold by saving in insurance premium.
A top up cover actually covers you after a “threshold limit” or “excess” is already exhausted or used. For example lets say you have a top up health cover of Rs 15 lacs sum assured with the threshold limit of Rs 5 lacs, in which the policy will only cover your expenses beyond Rs 5 lacs only. If your claim amount is Rs 9 lacs, then it will only pay you Rs 4 lacs (9 – 5), and NOT the entire Rs 9 lacs total. That’s the main difference between a regular health cover policy and a top up cover.
So now if you already have a health insurance cover of Rs 5 lacs sum assured, then you can take a top up cover up to Rs 15 lacs with threshold limit of Rs 5 lacs, that way you will be covered up to 15 lacs. The first policy will cover you up to Rs 5 lacs, and the top up cover will cover you for the 5-15 lacs. You can understand that more clearly with following image.
What is Super Top up cover?
The Super Top up cover is a enhanced cover while compare to the top up coverage .A top up cover will indemnify if claim amount is above the threshold. As mentioned in the previous example the top up cover will help us when the bill amount is above 5 lac each time ,where as if we have two bills of 4 lac each then the normal top up cover will not help because no single bill is above the threshold limit of 5 lac .That is where “Super Top us plans come in to picture, which takes consideration in to the total of the bills in a year and not a single instance, Hence in case of two bills of 4 lac each ,the total bill is 8 lac ,then super top up will trigger where a top up will not .
What are the general Waiting periods applicable in health insurance?
When you sign up for a new health insurance policy, it doesn't get implemented with immediate effect. The policy comes into effect after a 'waiting period', which depends on the kind of insurance and other factors, such as age, your medical history and the company. In other words, the insurer is liable to entertain any claim amount filed only after this waiting period. As mentioned earlier, the concept of waiting period exists across different kinds of insurance policies, and the quantum of waiting period may differ depending upon the insurer and the nature of the insurance policy.
However, following are the broad indicators of waiting period. There is an initial waiting period of 30 days, which goes up to 90 days in some cases, from the effective date of the policy. Some insurance policies may permit treatment for accidental external injuries with a minimum of 24-hour hospitalization.
Pre-existing diseases may not be covered in the first 2-4 years of the policy depending on your age and the nature of the policy. A pre-existing disease refers to any medical condition of an individual prior to the commencement of the policy. Now the policy may be effective for any other ailments in the first few years of the policy. Buy any claim filed for illness related to the pre-existing disease will not be covered in the first 1-4 years of the policy as stated in the policy document.
This feature is most common in insurance policies designed for senior citizens. Also, the insurer may insist that you stick with the same insurer if you want the cover to continue without further waiting periods in future.
The third is the ailment-specific waiting period, during which an ailment will not be covered. This again varies from company to company. But some common ailments that involve waiting periods include, ENT disorders, polycystic ovarian diseases, diabetes, osteosrthiritis, osteoporosis, hypertension and hernia. These ailments are usually covered only after two years from the date of commencement of the policy.
General Insurance
