Simplest Guide for Health Insurance in India

Health Insurance is the medical insurance provided to you by an insurance company, wherein it reimburses the medical expenses you incur as a result of your valid hospitalization. So here are some tips to buy health insurance in India:

• Understand your needs

First thing first, you need to ascertain your need to buy health insurance. Given the uncertainty and rising healthcare costs being reasons enough, you need to know who will be covered under the policy you take. If you wish to cover your family together, you may opt for a family floater while if you are going for only covering yourself then an individual policy would suffice. For your parents, you can opt for Senior citizen policy with shorter waiting period for the pre-existing diseases to be covered

• An exhaustive research:

Once you have ascertained who you wish to be covered under the health insurance policy, you then begin looking for the right kind of policy across the different options available under different companies. A Health Insurance broker will be the best person to buy health insurance policy from because he has an in-depth knowledge about many health insurance companies and will guide you towards a policy that is right for you.

To know more see Simple Steps to buying a Health Insurance cover!

R/S,
The total outstanding amount is Rs. 23056.50/- at this stage including follow up till 30th April 2010 not Rs. 19350 which is being shown by ” mediassist” on their website as above. Still not reimbursed. Why?
With Regards,
Raj Kumari ( Self-Policy Holder-Patient)
W/O Pardeep Kumar Grover
R/O:- AU-1, PITAM PURA, DELHI-88
PH- 91-011-27341158, 9250549600.
email: deepgro@yahoo.com

Subject: Protect my rights as a policy holder

Please find details regarding my case as discussed on phone.

Company Name: Reliance HealthWise Policy

MAID: 4007974461, Policy No.: 1302/792825012553-

R/S,

Madness prevails at ‘mediassist’ india private limited.
As evil prevails at ‘mediassist’ when good men do nothing.

For your kind information people at ‘mediassist’ india private limited have now started a last ditch effort to deny reimbursement of my dues amounting to Rs. 23056.50/-
They are only trying to save a little bounty out of a sick woman’s worst ever cries.

Please note that all the demanded documents relating to my two days hospitalisation till follow up treatment of my wife for one and half month with Original Receipts and other papers amounting to total claim amount Rs. 23056.50/- have been already deposited to ‘mediassist’ wide receipt no. 54 dated 13 may 2010, No. 2 dated 6th April 2010 and receipt no 43 dated 19th March 2010 by Mr. Raju.

The Fact should be duly noted that each and every information including the alleged demanded documents such as receipts, HW Claim Form and Past Policy Details etc. had already been physically got verified by the concerned executives personally who had attended me during my visits to mediassist’s office at Customer Service Department, Medi-Assist India TPA Private Limited, F-2, Kailash Plaza, H-252, (2nd Floor), Sant Nagar, East of Kailash, Delhi-110065.

And you know! I have every paper’s photocopy singly & separately got stamped with receipt nos. of 54 dated 13 may 2010, No. 2 dated 6th April 2010 and receipt no 43 dated 19th March 2010.

For Details please find attachment of related emails/letters.

Now it is my humble request to please help me and protect my rights as a policy holder so that I would get my claim reimbursed at the earliest possible without further delay from the dreaded clutches of an ‘evil’ TPA known as ‘Med Assist’ India Private Limited.

The total outstanding amount is Rs. 23056.50/- at this stage including follow up till 30th April 2010.

Thanking you in anticipation.

With Regards,

Dr. Pardeep Grover H/O Raj Kumari (Patient and the policy holder)
R/O:- AU-1, Pitam Pura, Delhi-88
Ph. Nos. 91-011-27341158, 9250549600.
Email: deepgro@yahoo.com

Many times there are cases that insured a person who files claim does not provide proper documents. In these cases the claims are rejected. So here is what to do after Health Insurance Claim Rejection:

• Know the reason from TPA
• Check the claim form
• Contact the TPA
• Check the documents submitted
• Gather medical proof
• File an appeal
• Approach Ombudsman

To read each in detail see Is your Claim rejected? Follow these steps!

A health insurance claim is a bill for health care services that your health care provider turns in to the insurance company for payment. So here are some reasons why your claim will not be paid:

• Ailment not being covered in the health insurance policy (Exclusion)
• Improper claim form filled
• Procedure deemed medically unnecessary
• Claim not filed in time

To know more see Is your Claim rejected? Follow these steps!

The ailment-specific waiting period

This refers to the number of years one has to wait for treatment of specific ailments to be payable under the health insurance policy. This differs from company to company. But generally, across all companies, during the period of insurance cover, the expenses on treatment of specific diseases and surgeries for specified periods are not payable if contracted during the early currency of the policy.

For instance,

• ENT disorders and surgeries, Polycystic ovarian diseases are covered only after 1 year from the date of commencement of the policy.            
• Diabetes, Hypertension, surgery of Hernia are payable only after 2 years from the date of commencement of the policy.
• Age related Osteoarthritis and Osteoporosis is payable only after 4 years from the date of commencement of the policy.

For this reason it is essential to completely be aware as to treatments for which all ailments are payable and after how many years as per the policy wordings of the company from which you have purchased your health insurance policy.

To know more see Waiting period in a Health Insurance Policy

 “Waiting period” is a part of your policy and determines from when you benefit from the policy, so it is pertinent that you have a complete understanding of the waiting periods in the health insurance policy you buy….

The initial waiting period

This refers to the 30 day waiting period – from the date of the commencement of the policy until the first 30 days – within which you will not be covered for treatment of any disease or ailment, except treatment for accidental external injuries that require 24 hours hospitalization.

To know more see Waiting period in a Health Insurance Policy

Ombudsman is generally appointed by the organization to act as an impartial judge who listens to both the sides and gives recommendations to settle the dispute. After listening to both the sides, if the matter is settled, Ombudsman makes recommendations that are fair to the case. He has to make those recommendations within one month and send the copies to the person who lodged the complaint and to the insurance company.

• If the complainant agrees,

The person who had complained has to send his reply saying whether or not he has accepted the settlement within 15 days of the recommendations. If the Ombudsman has recommended that the person complaining gets an award then the insurance company is binded to pay it. The payment has to be made within 3 months of the receipt of the recommendation.

• If the complainant disagrees,

If the recommendations of ombudsman do not satisfy the complainant, then he can send a reply rejecting the recommendation to both the ombudsman and the insurance company. He can then approach other forums like consumer forum or courts of law.

To know more see The Role of Ombudsman in Health Insurance in India

You need to lodge a written complaint addressed to the Insurance Ombudsman of your jurisdiction. You can find the insurance ombudsman of your jurisdiction through the document provided at the time of buying the policy or by referring to the IRDA website. You can approach ombudsman in cases like:

• If you think the insurance company has not fully paid a valid claim.
• If there is a disagreement about the payment of premium between the insurance company and you.
• If there is disagreement between the interpretation of the policy wordings.
• If there is delay in the payment of the claim.
• If the insurance company does not provide any insurance document after acceptance of the proposal and even after you have paid the premium.

To know more see The Role of Ombudsman in Health Insurance in India

a) Ambulance charges: Ambulance charges will be paid in case the person has to be shifted from residence to hospital in Emergency/ ICU or from one hospital/Nursing Home to another Hospital/ Nursing Home by registered ambulance only for better facilities.

It means that Ambulance charges will only be paid in case of emergency or when patient is shifted to other hospitals for better facilities.

b) Domiciliary treatment: Medical treatment exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at hospital/nursing as in- patient home but actually taken whilst confined at home in India under any of the following circumstances namely:

i)  The patient is in such a condition that he/she cannot be removed to the hospital / Nursing Home.

ii)  The patient cannot be removed to Hospital/ Nursing home due to lack of accommodation in any Hospital in that city/ town/village.

It means that when the patient is not in a condition to be moved or when there is no availability of  beds  in hospitals, the medical care taken at home is payable.

But you will not be paid for Pre and Post hospital Treatment and if you need treatment for diseases like Asthma, Bronchitis, Diabetes Mellitus, Cough, Colds, Arthritis, Gout, Rheumatism. Etc.

c) Diagnostic Tests: Generally Insurance Companies only pay for Diagnostic tests if the individual is found to be positive with disease specified and if the disease is covered in the policy. This expense is taken under the pre- hospitalization expenses.

All diagnostic tests done during valid hospitalizations are covered in the policy

Most policies however pay for such tests upto a percentage of Sum Insured after a given number of claim-free years of cover.

To know more see Understanding Hospitalization vis-à-vis insurance

These are medical expenses relevant to the disease that resulted in hospitalisation incurred during a period up to the number of days specified in the policy, after hospitalization for treatments of disease, illness or injury sustained as part of a claim admissible under the policy.

What it means: It means that all the medical expenses incurred after the hospitalization can be claimed by the individual if the hospitalization is covered. Generally medical expenses up to 60 days from date of discharge can be claimed by the person after submitting relevant documents and receipts.

To know more see Understanding Hospitalization vis-à-vis insurance