Simplest Guide for Health Insurance in India

A pre-existing disease refers to any illness, injury, or medical condition that existed prior to the date of the commencement of the policy. This can include Diabetes, Hypertension or even Cancer.

Treatments for pre-existing diseases are covered and are payable by the insurance company, but only after the policy has been effective for a certain amount of time. Waiting periods for pre existing diseases typically range from two to four years, depending upon the insurance company and the type of pre-existing disease.

For senior citizens though, there are plans that cover pre existing conditions after a waiting period between one to two years as well.

To know more see Waiting period in a Health Insurance Policy

Policy holders have to be aware of their rights and be proactive in their measures if they want to benefit from the Institute of Ombudsman which is created especially for their grievance.

Here are the things that you as a consumer should do,

1. Read the Policy wordings, Conditions

The golden rule in insurance is to know what exactly you are getting. So read the policy wordings carefully and ask an insurance agent or a broker to explain it to you before you buy the policy. Even as you attempt to contest your claim, have a thorough understanding of the policy wordings before you approach the Ombudsman.

2. Communicate with the Insurance Company for any grievance before approaching the Ombudsman

You may never need to approach the Ombudsman if you have an effective communication of your grievance with the Insurance Company. So write a detailed letter attaching the proper documents to the Insurance company, the company will be likely to settle the claim if it a valid one. Only if the Insurance Company fails to reply to your complaint or rejects it without satisfactory reasons must you approach the ombudsman.

3. Understand when to approach the Ombudsman

You cannot approach the ombudsman without first communicating with the Insurance Company. You need to read the policy wordings and understand when you can approach the ombudsman. When you follow the proper procedure you have better chances of getting a satisfactory response from both the company as well as the ombudsman.

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

Government of India created Institution of Insurance Ombudsman in 1998 to handle the grievances of consumers regarding insurance policies. This institution is of great importance to the consumers as they are given a platform to express their issues with Insurance companies and get the issues resolved. Since the institution of Ombudsman is for protecting the policy holder’s interest, it puts consumer’s faith in the insurance companies and ensures that insurance companies are accountable in their transactions. Generally ombudsman is a person appointed by the organization to resolve disputes between someone outside the organization and the organization.

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

The expenses on the treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout and Rheumatism, Calculus diseases, Joint replacement due to Degenerative Condition and age related Osteoarthritis and Osteoporosis are generally not payable until a specific period of time, which differs from company to company. The specific diseases may also differ with the company.

To know more see Your Mediclaim policy excludes these expenses

When it comes to finding the right insurance agent, many would agree that they have to have your best interest at heart. Unfortunately, it will take time for people to find the right insurance agent that caters to their needs. However, here are some tips for you:

• Knowledge: Again, a good insurance agent should also be a knowledgeable one. He must know everything about the particular policy and must also be knowledgeable about matters of health. For instance, if you want to undergo cosmetic dentistry, your agent should be able to tell you if or not it is covered, and if not, then why. He should also know as to how the particular policy that is suited to you, differs from the same kind of policy offered by a competitor health insurance company.

• Helpful: A good insurance agent is helpful, in the sense that he can help you process claims, get your papers in order, and if it may not be possible for you to contact the TPA, he can contact on your behalf and get your claims processed.

• Accessibility: Very importantly your agent must be accessible anytime you need his help.

To know more see Good Health Insurance agent

Health Insurance is the need of the hour. Health insurance is but a product which is packaged with benefits and risks and sold in the market. While there are a variety of such products from different companies that keep you involved, you need to know which one is the best as far as you are concerned and how does that one differ from the others. It is here that the role of a health expert comes in picture. Here are the benefits of buying health insurance from health expert:

• They match your needs with your policy:

As agents are paid a commission to sell policies of a particular insurance company, they can be more tilted towards selling you a policy than advising you on what is good for you. A Broker on the other hand gets a commission irrespective of which company’s policy he is selling, hence may be more objective.

While both these options are good, a broker who has a good amount of health knowledge is the best alternative. He is in a position to understand the policy wordings as well as know the key health issues. He will advise you to get a policy that will get you all the benefits (covers major diseases, less restrictions, has more network hospitals and fits your budget) that you need than get a policy which is just cheap.

• They coordinate with Hospitals and TPAs:

The role of the broker/agent does not just end when you buy a policy from him; it is the claims process when his performs his actual role. A Broker/Agent is a mediator who informs, advices you when you are hospitalized and at the same time is in communication with the TPA and the insurance company.

During Cashless Claims, the broker has to make sure that the transaction between the hospital and the TPA happens smoothly. A Broker who does not have the right health knowledge cannot help the customer well because he cannot converse with doctors and hospitals and cannot decipher the medical terminology in the documents. This is where a broker with good health knowledge comes handy.

To know more reasons see Health Insurance from Health experts

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

As Parents, we always think of our children before anything else. We are forever busy worrying about their health or safety and they are forever busy giving us reasons to worry! Put an end to this worry by insuring your kids for the following reasons:

• If there is an emergency and your kid needs to be hospitalized.
• When you are older, there might be pre-existing diseases, a waiting period or in some cases a need to undergo medical test.
• When your kid is young, there will be many years when there is no claim, thus you will be awarded bonuses and discounts that will be beneficial for your child when he grows up.

To know more see Don’t forget to cover your Kids!

The Insurer has rejected my wife’s Mediclaim Insurance claim stating that Obstructive Slppe Apnoea is a pre-existing disease and it was not disclosed at the time of taking the policy.

Please note that I came to knew about this disease only when the first time she was hospitalized and as per the medical Doctors it is a problem which is faced by 55% of Indian.

I have sent repeated mail to the insurer to give me a clarification for the same, but they have not yet replied me.

Request you to please help me.