Simplest Guide for Health Insurance in India

Cashless Service is a service through which all the medical bills are paid by the Insurance company directly to the hospital, and the insured has not to pay anything at all. Basically this service is only applicable in hospitals which are in the insurance company’s “network hospitals” list.  Every insurance policy has a list of hospitals where the insured can avail of this service. The policy holder simply has to call the toll free number present on the Health Card and then the co-ordination between the hospital and the company takes place.

To know more see Basics of a Health Insurance Policy

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

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

From the date on which the health insurance policy is issued to you until 30 days, there is a waiting period during hospitalization charges in cases of diseases, will not be payable. However, if you undergo emergency hospitalization as a result of an accident, then the 30 day waiting period is waived off and your expenses will be reimbursed. All the more, this 30 day waiting period is applicable on at the start of the policy, and not at times of policy renewal.

To read more see Health Insurance made Simple

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