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  • What do you mean by Family Floater Policy?
    Family Floater is one single policy that takes care of the hospitalization expenses of your entire family. The policy has one single sum insured, which can be utilized by any/all insured persons in any proportion or amount subject to maximum of overall limit of the policy sum insured.

    Quite often Family floater plans are better than buying separate individual policies. Family Floater plans takes care of all the medical expenses during sudden illness, surgeries and accidents.
  • What is Health Insurance?
    The term health insurance is a type of insurance that covers your medical expenses.

    A health insurance policy is a contract between an insurer and an individual /group in which the insurer agrees to provide specified health insurance cover at a particular "premium".
  • What are the forms of Health Insurance available?
    The commonest form of health insurance policies in India cover the expenses incurred on Hospitalization, though a variety of products are now available which offer a range of health covers, depending on the need and choice of the insured.

    The health insurer usually provides either direct payment to hospital (cashless facility) or reimburses the expenses associated with illnesses and injuries or disburses a fixed benefit on occurrence of an illness.

    The type and amount of health care costs that will be covered by the health plan are specified in advance.
  • Why is Health Insurance important?
    All of us should buy health insurance and for all members of our family, according to our needs. Buying health insurance protects us from the sudden, unexpected costs of hospitalization (or other covered health events, like critical illnesses) which would otherwise make a major dent into household savings or even lead to indebtedness.

    Each of us is exposed to various health hazards and a medical emergency can strike anyone of us without any prior warning. Healthcare is increasingly expensive, with technological advances, new procedures and more effective medicines that have also driven up the costs of healthcare.

    While these high treatment expenses may be beyond the reach of many, taking the security of health insurance is much more affordable.
  • What kinds of Health Insurance plans are available?
    Health insurance policies are available from a sum insured of Rs 5000 in micro-insurance policies to even a sum insured of Rs 50 lakhs or more in certain critical illness plans. Most insurers offer policies between 1 lakh to 5 lakh sum insured.

    As the room rents and other expenses payable by insurers are increasingly being linked to the sum insured opted for, it is advisable to take adequate cover from an early age, particularly because it may not be easy to increase the sum insured after a claim occurs.

    Also, while most non-life insurance companies offer health insurance policies for a duration of one year, there are policies that are issued for two, three, four and five years duration also.

    Life insurance companies have plans which could extend even longer in the duration. A Hospitalization policy covers, fully or partly, the actual cost of the treatment for hospital admissions during the policy period.

    This is a wider form of coverage applicable for various hospitalization expenses, including expenses before and after hospitalization for some specified period.

    Such policies may be available on individual sum insured basis, or on a family floater basis where the sum insured is shared across the family members.

    Another type of product, the Hospital Daily Cash Benefit policy, provides a fixed daily sum insured for each day of hospitalization. There may also be coverage for a higher daily benefit in case of ICU admissions or for specified illnesses or injuries.

    A Critical Illness benefit policy provides a fixed lumpsum amount to the insured in case of diagnosis of a specified illness or on undergoing a specified procedure.

    This amount is helpful in mitigating various direct and indirect financial consequences of a critical illness. Usually, once this lump sum is paid, the plan ceases to remain in force.

    There are also other types of products, which offer lumpsum payment on undergoing a specified surgery (Surgical Cash Benefit), and others catering to the needs of specified target audience like senior citizens.
  • What is cashless facility?
    Insurance companies have tie-up arrangements with several hospitals all over the country as part of their network.

    Under a health insurance policy offering cashless facility, a policyholder can take treatment in any of the network hospitals without having to pay the hospital bills as the payment is made to the hospital directly by the Third Party Administrator, on behalf of the insurance company.

    However, expenses beyond the limits or sub-limits allowed by the insurance policy or expenses not covered under the policy have to be settled by you directly with the hospital.

    Cashless facility, however, is not available if you take treatment in a hospital that is not in the network.
  • What are the tax benefits I get if I opt for Health Insurance?
    Health insurance comes with attractive tax benefits as an added incentive.

    There is an exclusive section of the Income Tax Act which provides tax benefits for health insurance, which is Section 80D, and which is unlike the section 80C applicable to Life Insurance wherein other form of investments/ expenditure also qualify for the deduction.

    Currently, purchasers of health insurance who have purchased the policy by any payment mode other than cash can avail of an annual deduction of Rs. 15,000 from their taxable income for payment of Health Insurance premium for self, spouse and dependent children.

    For senior citizens, this deduction is higher, and is Rs. 20,000.

    Further, since the financial year 2008-09, an additional Rs 15,000 is available as deduction for health insurance premium paid on behalf of parents, which again is Rs 20,000 if the parents are senior citizens.
  • What are the factors that affect Health Insurance premium?
    Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses. Previous medical history is another major factor that determines the premium.

    If no prior medical history exists, premium will automatically be lower. Claim free years can also be a factor in determining the cost of the premium as it might benefit you with certain percentage of discount.

    This will automatically help you reduce your premium.
  • What does a Health Insurance policy not cover?
    You must read the prospectus/ policy and understand what is not covered under it. Generally, pre-existing diseases (read the policy to understand what a pre-existing disease is defined as) are excluded under a Health Insurance policy.

    Further, the policy would generally exclude certain diseases from the first year of coverage and also impose a waiting period.

    There would also be certain standard exclusions such as cost of spectacles, contact lenses and hearing aids not being covered, dental treatment/surgery ( unless requiring hospitalization) not being covered, convalescence, general debility, congenital external defects, venereal disease, intentional self-injury, use of intoxicating drugs/alcohol, AIDS, expenses for diagnosis, x-ray or laboratory tests not consistent with the disease requiring hospitalization, treatment relating to pregnancy or child birth including cesarean section, Naturopathy treatment.
  • Is there any Waiting Period for claims under a policy?
    Yes. When you get a new policy, generally, there will be a 30 days waiting period starting from the policy inception date, during which period any hospitalization charges will not be payable by the insurance companies.

    However, this is not applicable to any emergency hospitalization occurring due to an accident. This waiting period will not be applicable for subsequent policies under renewal.
  • What is pre-existing condition in health insurance policy?
    It is a medical condition/disease that existed before you obtained health insurance policy, and it is significant, because the insurance companies do not cover such pre-existing conditions, within 48 months of prior to the 1st policy.

    It means, pre-existing conditions can be considered for payment after completion of 48 months of continuous insurance cover.
  • If my policy is not renewed in time before expiry date, will I be denied for renewal?
    The policy will be renewable provided you pay the premium within 15 days (called as Grace Period) of expiry date.

    However, coverage would not be available for the period for which no premium is received by the insurance company. The policy will lapse if the premium is not paid within the grace period.
  • Can I transfer my policy from one insurance company to another without losing the renewal benefits?
    Yes. The Insurance Regulatory and Development Authority (IRDA) has issued a circular making it effective from 1st October, 2011, which directs the insurance companies to allow portability from one insurance company to another and from one plan to another, without making the insured to lose the renewal credits for pre-existing conditions, enjoyed in the previous policy.

    However, this credit will be limited to the Sum Insured (including Bonus) under previous policy. For details, you may check with the insurance company.
  • What happens to the policy coverage after a claim is filed?
    After a claim is filed and settled, the policy coverage is reduced by the amount that has been paid out on settlement.

    For Example:

    In January you start a policy with a coverage of Rs 5 Lakh for the year. In April, you make a claim of Rs 2 lakh. The coverage available to you for the May to December will be the balance of Rs.3 lakh.
  • What is 'Any one illness'?
    'Any one illness' would mean the continuous period of illness, including relapse within a certain number of days as specified in the policy. Usually this is 45 days.
  • What is the maximum number of claims allowed over a year?
    Any number of claims is allowed during the policy period unless there is a specific cap prescribed in any policy. However the sum insured is the maximum limit under the policy.
  • What is "health check" facility?
    Some health insurance policies pay for specified expenses towards general health check up once in a few years. Normally this is available once in four years.
  • Does Health Insurance cover everything from accident, surgery, normal hospitalization ?
    Yes, Health Insurance covers you for everything, provided you were hospitalized, be it for any reason; due to accident, illness, or disease.

    If someone met with an accident and he is hospitalized, then his mediclaim policy will pay for his bills, no exceptions.
  • What are the advantages of sticking to one Health Insurance company for a long time?
    The plus point of sticking with one company is that if someone is suffering from any pre-existing disease at the time of commencement of policy, those complications will be covered after 4 years. Until portability is introduced in India, this is the single biggest advantage to stick with one company for long.

    Another advantage is that when you have a continued policy from any insurance company, after few years you get bonus or discount in premium.

    For example:

    Suppose you have a policy of 3 lacs and you are with the same insurer for past 4 years you can get a bonus of 50% i.e. you pay premium for 3 lac only but you get coverage of 4.5 lacs.

    Similarly some companies don't offer bonus but they offer discount in premium i.e. for coverage amount of 3 lacs you pay lesser premium than actual amount.

    So if you don't have any serious problems with the insurance company then it is better to stick to one company.
  • Can NRI's take health insurance? Can they travel to India for treatment and claim? What about emergency situations ?
    Yes NRI's can take Health insurance in India. They can definitely travel to India for treatment and can claim it. however they will have to show their residence proof, ITR and a few other documents. If they don't have those documents, then they are not eligible to get insured in India.

    The cost of treatment in India is different and cheaper than countries like USA, UK and other European countries. The premium amount computed depends on Indian conditions and parameters.

    So if a NRI has health insurance form Indian company, that person would be paying premium as per India actuaries and obviously cost of treatment in his residing country would be higher than India.

    For example:

    If a person get dengue and he is very critical and requires urgent hospitalization, the cost of treatment in India would come up to 1-2 lacs (and this is on higher side.)

    The same treatment would cost around 10-15 thousand dollars in US so this burns a hole in insurance companies' pocket. So for treatment the person has to come to India and they don't offer compensation for treatment there.
  • How to claim successfully in case of emergency and planned hospitalization?
    The most basic fundamental for a smooth claim process is keeping all your documents up to date. If you have a past history of illness, make sure that you submit those documents too, because the TPA department will come to know whether it's a pre-existing disease or not.

    While submitting your documents make sure that all the documents are proper and there is no missing document pertaining to your illness. This will just give a chance to TPAs to make excuses and you will have to run for your money.

    It's worth noting that in case of planned hospitalization, if you inform your mediclaim company in advance and take prior authorization, everything will be settled by the mediclaim company or TPA, without the policyholder been required to submit any document.
  • If there are no loading charges, can premium still change on renewal?
    This is a very big question with very easy answer..If you check the premium structure of any of the mediclaim company, either there premium is increasing every year or they have premium slab for different age groups; something like for age 30-35 premium is 4200 and from age 36-40 its 6700.

    So under this second policy, when the policy holder moves from age 35 to 36, his premium suddenly jumps by Rs 2500 and this is not loading. So yes, premium can/will increase irrespective of loading after certain age.
  • During the course of my treatment, can I change the hospitals?
    Yes it is possible to shift to another hospital for reasons of requirement, of better medical procedure.

    However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions.

    Note that it would be prudent if you check the network hospital list and go to the best hospital in the beginning itself rather than changing midway.
  • What are the situations under which one may be denied cashless hospitalization?
    1. If there is any doubt in the coverage of treatment of present ailment under the Policy if the information sent to TPA is insufficient to confirm coverage
    2. If the ailment/condition is not being covered under the policy.
    3. If the request for pre-authorization is not received by TPA in time. In such a situation, the Insured can take the treatment, pay for the treatment to the hospital and after discharge, send the claim to TPA for processing.
    4. In case the hospital in not on the panel of the company or the disease/illness is pre-existing and not covered for 4 years.
  • What is Domiciliary Hospitalization?
    Domiciliary Hospitalization means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely:

    i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home
    ii) The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein

    For smooth claim process, just take care that all your documents are in place and to be on a safer side have a report from your family doctor, stating that this person cannot move to nursing home/hospital due to such and such reasons.

    It just provides the proof and makes the process simpler. Note that every company does not offer this facility, you should check your policy document.

Some important exclusion under health insurance policy:

1. Pre-existing diseases i.e. Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company.
Pre existing diseases will be covered after a maximum of four years since the inception of the policy
2. Any disease contracted during the first 30 days of inception of policy except in case of injury arising out of accident
3. Certain diseases such as cataract, piles, hernia, and sinusitis etc. are excluded for specified periods if contracted or manifested during the currency of the policy.
4. Injury or Diseases directly or indirectly attributable to War, Invasion, Act of Foreign Enemy, War like operations.
5. Cosmetic, aesthetic treatment unless arising out of accident.
6. Cost of spectacles, contact lenses and hearing aids
7. Dental treatment or surgery of any kind unless requiring hospitalization
8. Charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations, without any treatment.
9. Naturopathy or other forms of local medication
10. Pregnancy & childbirth related diseases
11. Intentional self-injury / injury under influence of alcohol, drugs
12. Diseases such as HIV or AIDS
13. Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the attending physician.
14. Convalescence, general debility, run-down condition or test cure, congenital external diseases or defects or anomalies, sterility, venereal disease.
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