Simplest Guide for Health Insurance in India

Ombudsman is responsible for two main functions, firstly for reconciliation or settlement of a grievance between person who has a complaint and the insurance company and secondly to award compensation to the complainant. The awards that Ombudsman announces are binding on the Insurance companies.

Remember before lodging a complaint,

• You need to communicate to the insurance company about your grievance and if the company does not respond within a month or if the reply does not satisfy you, you can lodge the complaint.
• You need to lodge a complaint within a month of the insurance company’s response.
• You cannot lodge a complaint if the same case is pending before any court, any consumer forum or arbitrator.

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

Hospital means any institution in India established for the indoor medical care and treatment of patients and which either:

a) Is registered and licensed as a hospital or nursing home with the appropriate local authorities and is under the Supervision of a Doctor in attendance 24 hours a day and is not, except incidentally, a clinic, nursing home, rest home, or convalescent home for the addicted, aged, mentally disturbed or similar institution, or

b) Complies with at least the following criteria:

i) It has at least 10 inpatient beds;

ii) It has a fully equipped and functioning operating theatre;

iii) It has qualified nursing staff (any person who holds a certificate issued by a recognized nursing council) in attendance 24 hours per day;

iv)It has a Doctor who is in attendance 24 hours per day;

v) It maintains daily medical records for each of its patients

What it means: It means that you can’t just go to any hospital in your neighborhood or admit yourself in your General Physician’s clinic with two beds. Health Insurance Companies in order to ensure quality and standard care to the patients make these conditions mandatory.

So before you get yourself or someone near you admitted make sure these basic conditions are fulfilled.

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

It is important to know the exclusions in your health insurance policy, because it may be that sometimes after a hospital stay you could actually get a bill for an item that was already paid for by your insurance and you didn’t even know it. There are certain diseases and injuries that are not covered by this policy.

• Pre-existing diseases & Specific ailments upto certain period
• Resulting from War
• Dental Care, Hearing and Vision care
• Cosmetic surgery
• Abortion
• Alternative therapies

To know each in detail see Your Mediclaim policy excludes these expenses

An insurance policy is issued for a limited time, and, at the end of that period, the insurance company renews the policy. You have to be punctual on your health policy renewal if you have already made a claim on your policy. This is because, if you miss your renewal date, then for the new policy your previous claim will be considered as a pre-existing disease/illness and will not be covered. Renewal dates are important times for insurance companies and policyholders. Here are a few things you will need to know before the renewal of your policy.

• The renewal date
• No claim bonus
• The documents

To read them all see Things to know before Renewal of policy

The broker acts as a bridge between the insurance company and you. He is the one who can give you an insight as to out of about 50 companies, which one best suits you after an exhaustive research and expertise, and experience in the field. But in case you are not happy with your broker then follow these steps below:

• You can change your Agent or the Broker at the time of the renewal. To know the date of the renewal, check your policy document.
• Write a letter naming the new agent/ broker and authorizing him/her to carry all transactions regarding your health insurance.
• For Private Companies: This letter along with the renewal notice and the cheque are all you need when you have bought a health insurance policy from a Private company (Apollo DKV, Bajaj, Star health etc).
• In case you don’t have the renewal notice, then you can provide a copy of last year’s policy to the Insurance Company.
• For Public Sector Companies: For Public Sector health insurance companies (Oriental, United India, National and New India) you must have the renewal notice along with the mandate to change your broker.
• In case you don’t have the renewal notice, then you will have to apply to get a no claim confirmation from the TPA or Third Party Administrator and you may even need to refill the proposal form and submit your photographs along with the last year’s policy if the branch of the company is also to be changed.

To read more see Change Broker/Agent

Health insurance comes under the General Insurance, and all health insurance policies are issued for a period of one year only. The maximum period can be two years, if a company issues a two year policy. But it is important to keep renewing your policy at the end of the period, either one or two years.

Because if the policy is not renewed in time, it may lapse, and you will have to wait for another four years for your claims to be redeemed, when you opt for another health insurance policy with a different company.

To know more health insurance see Health Insurance made Simple

Do you read the warranties on every product you purchase and the terms and conditions on every website that you visit? Do you even bother to read every cash register receipt to confirm the time that a store allows for returns? Do you read policy wordings while buying health insurance? I didn’t think so. If you don’t read them all, you will regret later on. So of the important fine prints are:

• Waiting Period & Other Diseases: It is very important to understand that you are not going to get cover from the first day after buying a policy. You cannot ask for any claim settlements from insurance company for a period 30days from the first date of commencement of the policy.
• Pre Existing Diseases: All the pre existing diseases are covered after a period of 4 years by Health Insurance Company. So it is always advisable not to ask for claim reimbursement for which you won’t get any help from Health Insurance Company result in empting your pocket.
• Renewal Ceasing Age and Age Brackets: There is no indication of renewal ceasing age in the policy wording. It is very important to clarify this point with your agent/broker while buying a policy.
• Renewal of the Policy: What many people don’t know is that Insurance Company is not bound to remind you for policy renewal. It is better to renew the policy before the date of expiry.

To read more points see 6 Hidden Fine Prints You Must Know

If you are alive and breathing, you NEED health insurance. Not a maybe, not an “Oh, I’ll wait and see.” You definitely need it! Why? If you think you do not need Health Insurance; then think again. Here are some reasons why people think they don’t need health insurance:

• People think there are no returns in health insurance. This generally happens because people don’t know much about how health insurance works and how different it is from general and life insurance.
• People think they are fit to not have health insurance. In country like India, people are very ignorant about their health. They only take policy when they feel they need it ignoring the benefits of having a health insurance policy.
• Many people are of the view that they can afford to pay for the medical bills if anything goes wrong with their health. With rising medical costs one may afford it today but you cannot predict for tomorrow.

To know more such vague reasons see Excuse for not buying Health insurance

Health insurance in India was a nonexistent industry till about 20 years ago but health insurance today has become a necessity and will be more so tomorrow. What reasons lead them for not having a health insurance? Let’s have a look at common things which results in not buying a health insurance:

• Lack of Awareness: The only reason is that there is lack of awareness about health insurance. In country like India, people are very ignorant about their health. They only take policy when they feel they need it ignoring the benefits of having a health insurance policy.
• Lack of Good Advisors: People generally feel that there are no good advisors who can help them in buying a policy. It is always advisable to seek an advice from brokers as they give unbiased opinions about all the insurance companies and offer you variety of options to choose from which a company agent won’t provide you.
• Money: The first and the foremost thing people think, before buying a health insurance is that they think it is a waste of money. Other reason for not buying is that, they don’t have surplus money to invest on health insurance.

To know more such points see Excuse for not buying Health insurance

Hospital Cash Insurance Policy is not a Health Policy. Hospital cash plan make a fixed payout depending on the plan chosen for each day of hospitalization on qualifying minimum hospitalization criteria set by the insurance company. This payout is fixed irrespective of the hospitalization expenses or payout from any other plan. These plans can be used as a compliment to health insurance plan.

To read more check Cash Health Plan is not Regular Health Insurance