Parameters of Health Insurance Plan

1) Maximum renewal age: This is the maximum age an individual can receive insurance coverage. This is the most important factor. As the need for insurance coverage increases with age, you will find it more difficult to get the policy renewed.

2) Sub Limits: These are limitations that apply to the various expenses covered by the policy. This is a limit that the insurer will pay for an expense incurred in a treatment. E.g. Some insurance companies have a maximum amount they will reimburse for room rent. In such cases, if you incur an expense that exceeds the amount stated by the insurer’s policy, you will need to pay the remainder. Other sub-limits would apply, such as doctor’s consultation.

3) Maximum coverage: This indicates the maximum amount that an individual can be covered. Each insurance company offers its own policy regarding the amount of coverage. Our needs and our ability to pay premiums will determine the type of cover we choose. The insurer will determine the sum assured. It can range from 2 lakhs up to 50 lakhs.

4) Pre- and Post-hospitalization Expenses This covers the costs of any medical tests, medications, or scans that were performed during the time period before and after the hospitalization. The time covered depends on the insurer. It could be as little as 30 days prior to the hospitalization or as long at 180 days after.

Pre-existing diseases: Insurance companies may cover pre-existing diseases after a period of continuous renewals. E.g. A policyholder with diabetes would be covered, depending on his age and plan after a waiting period between 3-4 years. Choose the plan that has the shortest waiting period.

6) Daycare treatments: Certain diseases and treatments are covered, even if they do not require 24-hour hospitalization. This is generally a mandatory clause. This could be because of the shorter time required for treatment due to technological changes. E.g Cataract surgery.

7) Ambulance Fees: If a policyholder is hospitalized, insurance companies will reimburse the cost for transport by ambulance. Each company is responsible for paying ambulance charges.

8) Medical Testing: Companies provide a list of pre-defined medical tests that an individual must undergo if he or she is over 45 years old, or if the amount requested exceeds a specific amount. There are many requirements for testing. These tests are also fully paid for by the insurance company.

9) No Claim Bonus: Policyholders who have not claimed in the past year are eligible for the ‘no-claim bonus’. This bonus can be reduced or increased in premium at the current premium amount.

10) tax benefit: Premiums can be deducted from income taxes under section 80 (C).

11) Allopathic treatment: Some insurance companies offer coverage for homeopathy, unnani, and ayurved treatments.

12) Other surgeries: Most insurance companies do not cover cosmetic surgery, dental implants, or weight loss procedures.

13) Network hospitals: These hospitals have a partnership with insurance companies to offer cashless treatment. You are eligible for treatment without payment if you have a TPA (third Party administrator) health card.

14) Domiciliary Care: Many times, the patient must be treated at home as they cannot be transported to the hospital. Many insurance companies will reimburse the patient for any treatment that is required in such cases.

15) The co payment refers to a division between the policyholders and the insurance company. If a company has a 10% co-pay option, then you will be required to pay 10% and the insurer the remaining 90%.

16) Claims Loading : Every premium after a year of claim has been made is loaded with additional charges. The amount of coverage claimed will determine the charges. Premium loading can be quite high in some cases, so make sure to check the additional premium charges that are imposed by the companies.

17) Exclusions – There are some diseases that insurance companies do not cover. These exclusions include permanent exclusions like AIDS, drug abuse, and mental disorders. There are however, certain exclusions that can be considered if certain conditions are met.