Health Insurance/Mediclaim – Frequently Asked Questions

Mediclaim & Health Insurance Policies

Mediclaim & Health Insurance Policies

What is Health Insurance/Mediclaim?

Health insurance is a type of insurance coverage that protects an individual or a group of people against medical and surgical costs against payment of regular premiums.

Why do I need health insurance?

Mounting healthcare and surgical costs are a major strain on household budgets. Like any other insurance, mediclaim or health insurance is the best possible protection you or your family may have against any medical (usually hospitalization or surgical) costs. Health insurance also makes medical help affordable for everyone.

Does health insurance provide tax benefits?

Mediclaim or health insurance makes you eligible for tax benefits on premium paid under 80D of the Income Tax Act.

What is the right age to get health insurance?

Given the current healthcare scenario, there is no right age to get medical insurance – the earlier, the better. Children can be added to either parent’s mediclaim policy. Many health insurance providers also have special plans for senior citizens and old age related health costs.

What are the types of health insurance available?

Most health insurance providers offer customized mediclaim or health plans. They are broadly of 4 types –
• Individual health plan
• Family health plan
• Critical illness plan
• Senior citizen health plan

Accident-related medical costs are generally covered by all health insurance plans or may be taken as an add-on rider.

How much does health insurance cost?

Health insurance costs vary depending on the following factors –
• Company providing the insurance
• Number of persons covered
• Age of the person/persons assured
• Health of the person/persons assured
• Location (health risks in metros is deemed more than that of people residing in small cities and villages)
• Additional riders (if any are opted for)

Does premium remain constant always?

When a person signs up for a health insurance, the insurance company ascertains premium based on a number of criteria. Once determined, the company usually charges the same premium for that age group. The older a policy holder gets, the more the premium amount is. In the meantime, if there is a claim in any year, the premium may be hiked upon policy renewal. This is called load premium. The insurance company may sometimes offer a discount on premium, if no claim is registered for a number of years.

What is TPA?

TPA refers to a Third Party Administrator or an entity separate from the insurer or the policy holder. A TPA processes medical claims and provides cashless services to the policy holder.

What are common exclusions to Mediclaim policies?

Mediclaim health insurance policies usually do not cover the following –
• Congenital medical conditions and diseases
• Pre-existing diseases diagnosed prior to policy issuance
• Medical costs arising out of self-inflicted injuries and/or attempted suicide
• Cosmetic surgeries and/or treatments including dental treatment
• Drunken driving related accidents
• Cost of spectacles or contact lenses
• Treatment of HIV/AIDS

Does health insurance cover non allopathic treatment?

Most insurers do not cover non allopathic treatments. Do read the insurance offer document before taking the policy.

What will a health insurance policy pay for?

• Pre-Hospitalization – Medical expenditure incurred immediately before hospitalization, leading up to the hospitalization.
• In-patient Treatment – Hospitalization expenses including room charges, surgical costs, doctors’ fees, medicines, nursing expenses, and all other related expenses.
• Post-Hospitalization – Medical expenses incurred immediately after the discharge from hospital such as medicines, follow-up treatment costs.
• Day care treatment –Treatment at a hospital for less than 24 hours, when hospitalization is not deemed necessary due to technological advancement.
• Domiciliary Hospitalization – The condition of the policy holder is critical and thus care and treatment are provided at home instead of hospitalization.

A number of recent health insurance policies also cover outpatient treatment, though this is not covered by mediclaim policies in general. Also most health insurance policies cover critical illnesses such as cancer as an optional rider.

Does health insurance cover diagnostics such as X-ray and MRI?

Generally most health insurance policies do not cover diagnostic expenses unless they are part of the hospitalization charges or incurred as part of the pre-hospitalization or post-hospitalization expenses.

What does ‘cashless hospitalization’ mean?

Cashless hospitalization is a process by which a health insurance policy holder can seek admission to any hospital authorized by the insurance company and undergo medical treatment and/or surgery without paying directly for the treatment. The medical expenses as eligible will in this case be paid by the insurance company directly to the hospital.

How will I know if a hospital is authorized for cashless benefits?

Usually, an insurance company sends its policy holders a list of “cashless” hospitals in its panel each year. In case of a planned hospitalization, please consult the TPA/insurance company beforehand.

How should I make a claim?

Planned hospitalization – Submit a written application with the TPA. Include doctor’s recommendation for hospitalization, medical records, and planned expenses. Once approval comes through go ahead with hospitalization. Notify TPA and make a claim through the hospital to avail cashless benefits.

Unplanned hospitalization/Accidents – Notify TPA within 24 hours of hospitalization. Submit a notification statement with name, policy number, and known medical details. The insurer is likely to clear your eligibility details within a day or two. Stake cashless claim through the hospital to avail cashless services or pay cash and stake claim with all bills and records at the completion of treatment.

What is cumulative bonus?

Cumulative bonus is an addition to the sum assured provided by the insurance company without charging additional premium. It is provided for every year of the policy in which the holder does not register a claim.
Where can I file a complaint if an insurance company refuses to pay or if I am unhappy with the settlement amount?

The insurance complaints redressal system in India is a strong one. The Insurance Regulatory and Development Authority (IRDA) has implemented an Integrated Grievance Management System (IGMS) for insurance policy holders to register any complaints. When complaints raised with insurance companies are not addressed adequately and if a resolution is not reached these may be escalated to the IRDA’s Grievance Cell.

IRDA Grievance Call Centre (IGCC) toll free number- 155255 (voice call)
E-mail – [email protected]