Simplest Guide for Health Insurance in India

Almost all health insurance companies give a free health check up to the customers who have completed three or four claim free years without break with the company. You need to conduct these tests in the authorized diagnostic centers.

• For Policies from Private Health Insurance Companies: You will get a Health Checkup coupon at the time of the renewal of health insurance policy on completion of your three of four claim free years. You need to take this coupon to an authorized diagnostic centre (list, mentioned on the coupon) to undergo the check up.
• For Policies from Public Health Insurance Companies: You need to get the ‘No Claim Confirmation’ from the TPA after completion of the required claim free years. You can get a checkup done free of cost upto 1% of the sum assured. Send your original bills to Health insurance Company for reimbursement.

To read more such information see Why aren’t Diagnostic Tests Covered in Health Insurance?

Though regular health insurance policies do not cover OPD expenses there are certain policies like  ICICI Lombard’s Health advantage, Star’ Health Gain and Apollo’s Maxima health plan. These plans cover your OPD expenses including dental, consultation and Diagnostic tests expenses upto a limit. You have to keep all the bills with you and reimburse the amount once in a year. Though this benefit is a good one, the premium slabs are greater compared to other policies for the same sum assured.

To read more such information see Why aren’t Diagnostic Tests Covered in Health Insurance?

OPD expenses like consultation fees, expenses on medicines, dental expenses are not payable in India, but if:

• You are hospitalized due to findings of the test you took. Also note that the tests are payable only if they are a part of your treatment

• If you require these diagnostic tests as part of the treatment for which you are hospitalized. That is if your doctor ordered some blood tests, x ray tests while your stay in the hospitalization, these are payable.

Note: There may be sub limits on these for example – in National insurance, “Anesthesia, Blood, Oxygen, OT charges, surgical appliance, Medicines, drugs, Diagnostic Material & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant. Maximum limit per illness – 50% of Sum Insured.”

To read more such information see Why aren’t Diagnostic Tests Covered in Health Insurance?

Unlike in some of the other countries which provide a universal health care system, Health insurance in India is restricted to hospitalization, which means that health insurance companies will only pay claims pertaining to medical expenses related to hospitalization. Thus all OPD expenses like consultation fees, expenses on medicines, dental expenses are not payable. So even if some of the tests for example- MRI scans, are very expensive, they are not payable in most of the health insurance policies.

To read more such information see Why aren’t Diagnostic Tests Covered in Health Insurance?

General insurance companies offer health policies which are mainly short term in nature. This means, that the health insurance policies can be renewed year after year and the premium amount varies with age.

Health insurance covers offered under general insurance, include mainly hospitalization covers either on reimbursement or cashless basis. The Third Party Administrators (TPAs) mainly offer cashless service as they have arrangements with various hospitals, who are the service providers. The TPAs also help in reimbursement claims.

To read more see Health Insurance by Life and General Insurance Cos

There are various life insurance companies that offer health benefits and packages. Firstly, the health related policies under life insurance companies cover certain critical illnesses. For example, certain private companies that offer life insurance to customers cover about 36 critical illnesses which include heart attacks, stroke, cancer, paralysis etc. Now this in turn means that once a person visits a doctor for treatment, and if the doctor then after diagnosis confirms a serious illness, then on the basis of the doctor’s report, the insured will get a lump sum amount from the company.

Health Insurance policies by life insurance companies are long term plans (over 10, 20 years and above)

One of the prime ways in which life insurance companies tend to sell health policies are mostly in the form of investment plans. These are essentially known as Health ULIP plans. However the difference in these plans and others lies with regard to:

• the hidden charges which are high ,
• a waiting period of three years before which you cannot claim,
• High premium rates.

To read more see Health Insurance by Life and General Insurance Cos

Having an efficient agent/broker who understands health and health insurance would be key in getting valid and correct claims documents to reach your TPA in time.

Call the TPA (Third Party Administrator) immediately you know about the hospitalisation schedule and within 24 hours of admission to hospital if it’s an emergency hospitalisation.

• Also write a mail or send a fax to the TPA or the health insurance company informing them about the hospitalization within the aforesaid time frame (this is because many health insurance companies recognize written communication only. You will also have a record of having provided the intimation.)
• The TPA or Health Insurance Company will provide you the intimation number through mail or sms but if they don’t, you must call them up and ask for the claim intimation number. This number is important for you to establish that your claim is duly intimated and is a helpful identity later in getting your claim processed and settled, so make sure you receive it.

For Documents Submission:

• Fill in the claim form provided in the company website or available with your Agent or Broker with details like your complete name, age, gender,  date of hospitalization, date of discharge, name of the hospital/nursing home, name of the medical practitioner, etc.
• Attach all the necessary claim documents (mentioned in policy wordings in the Claims Notice section) with the claim form and send it to the TPA or the Health insurance Company as mentioned in the policy within 7 days of from date of discharge, and get the same duly acknowledged with the time and date of receipt.

To read more see Health Insurance Claim Documents Submitted beyond 7 days rejected!

Insurance Companies recently instructed TPAs to reject claims documents for which are submitted beyond 7 days from the date of discharge. So first, call the TPA (Third Party Administrator) immediately you know about the hospitalisation schedule and within 24 hours of admission to hospital if it’s an emergency hospitalisation. Instead of the 30 days window you could submit your documents, you now have just a week – which for someone who is working even 5 days a week, is almost like submitting the documents as soon as the discharge happens. This basically means you need to intimate claim within 1 day of admission and submit your claim documents within 7 days of discharge.

To read more see Health Insurance Claim Documents Submitted beyond 7 days rejected!

Most times, even Health Insurance agents desist from giving out full information in regards with a Mediclaim policy; the best option in times like this is to opt for a knowledgeable Health Insurance Broker! And here is what you should look out for while buying health insurance in India:

• Payment Options

• Network Hospitals                

• List of Exclusions

• Waiting Period

• Policy Sub-Limits

To read each in detail see Checklist for Buying Health Insurance