FAQs

In this section you will find answers to frequently asked questions on life, health, travel and home insurance, savings, loans, mortgages and personal finance.

Health Insurance (32)

Health Insurance protects you against rising healthcare costs and financial uncertainty associated with unforeseen hospitalisation due to accidents or illnesses. You can secure yourself and your family against unexpected financial emergencies by taking a health insurance policy for yourself and your family.

Major illnesses or accidents that require hospitalization can significantly deplete an individual’s finances. Costs for treatment of an illness requiring prolonged hospital care can sometimes be fairly expensive and due care should be taken while choosing the adequate amount of cover that you should insure for. Health Insurance is also important to those who do not have a guaranteed health cover as provided to government or armed forces employees. Group health insurance cover that may be provided by an Employer is subject to continued employment and the terms of the group cover – which may or may not be renewed in the future, or may not be provided post retirement.

With increasing age, need for healthcare typically increases – and many employer provided insurance covers may not provide the cover at the time.

It is important that provision for health insurance is done at an early age. Different health insurance policies have different rules for underwriting, covering pre-existing diseases, exclusions, and eligibility for certain types of charges covered or room type / room cost per day.

It is important that in taking a health insurance cover, proper research and comparison is done on the various products in order to decide which ones meet your requirements best. This is not only a function of price. Some plans will also offer hospital cash benefits to cover ‘other’ expenses when hospitalized or out-patient or dental expenses.

One can consider either an Individual Plan or a Family Floater which provides for cover for the family. A Family Floater can be cheaper than a combination of Individual plans, but limits the payments covered to the overall sum insured in a given year.

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A family floater policy covers all family members (Insured, his/her spouse and children) under one single policy. The Sum Insured floats over the entire Family and a consolidated premium needs to be paid. There is a limit on the no. of children that can be included and age before and beyond which they are not covered which varies from policy to policy. Parents of the insured are typically not included in a family floater policy.

An individual policy, on the other hand, provides health insurance coverage to only the individual for whom the insurance has been purchased.

While a family floater may turn out to be cheaper than taking 2 or more individual policies, the associated cover provided is at a family level. For e.g. if you take 2 Individual policies with a Rs. 200,000 Sum Assured each for yourself and your spouse, then both of you are covered for Rs. 200,000 each. However, if you take a family floater with a Rs. 200,000 Sum Assured then this limit applies to the two of you together.

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1. It is always better to start your coverage at an early age.
o With age the risk to our health only increases, consequently making insurance more expensive with age
o What is also an important consideration is that most companies are now providing guaranteed renewals for life once you are issued a health insurance policy and you are most likely to ‘get in’ when young
o Another key factor is the existence of an exclusion period (generally 2-4 years) for certain illnesses or medical conditions. One could, most likely, see through this exclusion period without any complications in the early part of one’s life and be covered for such conditions at a later stage

2. Make sure that you insure yourself and / or your family for an adequate amount of cover.
o While choosing this amount do take into account the costs associated with the treatments on conditions that you want to insure for as well as your premium paying capacity.
o Do not restrict your cover to the nominal amount that may be required to meet your tax exemption limits only
o You could always choose from between Individual Health Plans that provide cover for an individual or Family Floater policies that cover the entire family (usually restricted to self, spouse and children – parents are not covered under such plans). While a family floater may turn out to be cheaper than taking 2 or more individual policies, the associated cover provided is at a family level. For e.g. if you take 2 Individual policies with a Rs. 200,000 Sum Assured each for yourself and your spouse, then both of you are covered for Rs. 200,000 each. However, if you take a family floater with a Rs. 200,000 Sum Assured then this limit applies to the two of you together

3. While you will surely compare premiums associated with various products that you compare, make sure you consider some of these features as well:
o Cashless hospitalisation: a facility in which a person can get the required treatment while the medical expenses are settled by the insurance company directly with the hospital if the hospital comes under its network. You may, therefore, also want to compare the associated network of hospitals of each insurer.
o Cumulative Bonuses or Premium Discount: Some products carry incentives for ‘claim free’ years and offer either an increased Sum Assured for no extra cost or a reduced premium for your Sum Assured
o Exclusions: Do carefully review the exclusion list of each product. Needless to say, for the same amount of cost you would want to go for the product that has the least number of exclusions. Alternately, you may want to be covered for a specific medical condition which may actually be excluded in a given product.
o Maximum age of Renewal: This is the age to which the company would continue to provide you with health insurance on payment of premiums. You may want to go for a product with a higher maximum age of renewal.
o Other benefits: You may also want to compare certain other benefits such as Ambulance charges, coverage for day care procedures (for which hospitalization is not required) etc.

It is always important to carefully review the products’ benefits, terms and conditions and associated features – get complete information on available choices and compare before you buy. As we keep saying Health Insured is Wealth Protected.

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While you will surely compare premiums associated with various products that you compare, make sure you consider some of these features as well:

o Cashless hospitalisation: a facility in which a person can get the required treatment while the medical expenses are settled by the insurance company directly with the hospital if the hospital comes under its network. You may, therefore, also want to compare the associated network of hospitals of each insurer.
o No Claim Bonus or Discount: Some products carry incentives for ‘claim free’ years and offer either an increased Sum Assured for no extra cost or a reduced premium for your Sum Assured
o Exclusions: Do carefully review the exclusion list of each product. Needless to say, for the same amount of cost you would want to go for the product that has the least number of exclusions. Alternately, you may want to be covered for a specific medical condition which may actually be excluded in a given product.
o Maximum age of Renewal: This is the age to which the company would continue to provide you with health insurance on payment of premiums. You may want to go for a product with a higher maximum age of renewal.
Other benefits: You may also want to compare certain other benefits such as Ambulance charges, coverage for day care procedures (for which hospitalization is not required) etc.

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A Critical illness cover is generally available as a top-up or rider with your health insurance policy. As the name suggests, these plans cover you for certain specific critical illnesses that are pre-defined as being covered under the plan.

Under these plans, the insured is paid the Sum Assured as a lump sum amount within a few days of a critical illnesses being diagnosed.

Once this lump sum is paid, the plan ceases to exist. The differences between a Health Insurance policy and a Critical Illness plan are:
• Health Insurance plans cover costs related to hospitalisation on account of any medical condition or injury while Critical Illness plans cover only pre-specified illnesses
• Health Insurance plans continue their coverage till the time the Sum Assured is not exhausted by claims during a year. Critical Illness plans, on the other hand, pay up the Sum Assured and cease to exist as soon as a critical illness is diagnosed
The list of the critical illnesses covered varies from insurer to insurer and one should carefully review the coverage parameters before purchasing a policy.

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All pre-existing illnesses at the time of taking the policy are generally excluded from the health insurance cover. However, in some products pre-existing illnesses may be covered after a specified waiting period. What this means is that if you continue with an insurance product (i.e. keep renewing your policy) for the specified period then certain pre-existing illnesses may be covered on the completion of the waiting period. This waiting period varies by product and insurance company.

It is always important to carefully review the products’ benefits, terms and conditions and associated features – get complete information on available choices and compare before you buy.

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Documentation requirements at the time of purchasing a health insurance policy vary from company to company. However, most companies would require the following:
• Dully filled up proposal form of the insurance company.
• Medical examination report (this would depend on whether or not a medical examination is required for your age and the amount of cover you wish to purchase)
• Photograph of the person(s) to be insured.
• Photo ID proof of the proposer.
• Cheque issued by the proposer or Online Payment confirmation.

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A health insurance policy is generally issued for a period of 1 year, at the end of which you need to renew your policy. Some companies, however, also offer policies for a duration of 2 years. For some products, the renewal of the policy will be at the discretion of the insurance company and would depend on a review of health conditions and a possible medical examination.

However, in other cases, a renewal is guaranteed up to the maximum age of coverage under the product, as long as the required premium is paid. For e.g. if you purchase a health insurance policy at the age of 35 and the product provides a health cover up to a maximum age of 70, then you will be assured of a health insurance cover to age 70 years on payment of applicable premiums every year.

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The minimum and maximum ages for a health insurance product vary from company to company and are also product specific. While you will need to be at least 18 years of age to buy a health insurance policy for yourself, you could purchase insurance for your children starting almost at the time of birth in some products. You could insure your children through either an individual policy or cover them through family floater policy.

The maximum age for buying a health insurance is typically 60, but some products allow a person to buy an insurance cover upto Age 65.
The maximum age for renewal of an existing policy again depends product to product but most products provide a cover till the age of 70; with some covering till age 80.

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The minimum and maximum Sum Assured vary by product, insurance type and insurance company. However, one should keep various factors in mind when choosing the adequate amount of cover for yourself and your family.

Use our health insurance calculator to help you decide the amount of health insurance you may need.

While choosing this amount do take into account the costs associated with the treatments on conditions that you want to insure for as well as your premium paying capacity.

Do not restrict your cover to the nominal amount that may be required to meet your tax exemption limits only.

You could always choose from between Individual Health Plans that provide cover for an individual or Family Floater policies that cover the entire family (usually restricted to self, spouse and children – parents are not covered under such plans). While a family floater may turn out to be cheaper than taking 2 or more individual policies, the associated cover provided is at a family level. For e.g. if you take 2 Individual policies with a Rs. 200,000 Sum Assured each for yourself and your spouse, then both of you are covered for Rs. 200,000 each. However, if you take a family floater with a Rs. 200,000 Sum Assured then this limit applies to the two of you together

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Most health insurance policies have a waiting period of that may vary from 30-90 days, during which no claims are permissible. However this doesn’t include any accidental emergencies which are usually covered from day 1. The waiting period varies with product and company and is a feature that you should compare at the time of purchasing health insurance.

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Most products available in the market do not cover parents as part of the family floater policies. To cover your parents, you may need to purchase individual insurance plans.

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Your employer will cover your medical expenses only as long as you are in his services. Tomorrow, you may change your job, retire, or even start something on your own. In all such cases you and your family will be stranded if a medical emergency arises and you have not arranged for an alternative health insurance policy. It can act as a supplement to your existing medical cover in case the cost of medical treatment is higher than your existing cover level.

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Yes, you can buy more than one insurance policy. This may be done to get yourself covered for a larger amount or to avail oneself with benefits which were not covered in the previous policy. However, a claim for a single “event” can be made only once. In the event a claim for one “event” is made to multiple insurers, a proportional rule will apply and the Insurers will pay a part of the insurance claim each, such that the maximum payout will not exceed the maximum amount payable after applicable deductions and limits as stated in the Insurance policy.

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For the financial year 2017-18, Premiums upto Rs 25,000 on policies taken for for self, spouse and dependent children are eligible for tax deduction under Section 80D of the Income Tax Act.

An additional deduction of Rs 25,000 is allowed for premiums paid on health insurance policies purchased for parents. If any one of the persons specified is a senior citizen (Age 60 years and above) and health Insurance premium is paid for such senior citizen then the deduction amount is Rs. 30,000.

Please consult your tax advisor.

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Most health insurance companies provide the feature of ‘cashless facility’ with a select network of hospitals. This means that you can walk into any of the networked hospitals across the country and get treated (for diseases which fall under purview of cover) without having to pay for your bills first and then claiming it from insurance companies. The expenses are settled directly between the insurer and the hospital.

If you do not get admitted to a networked hospital due to some reasons, you will need to settle the hospitalization expenses and claim these from the insurance company subsequently.

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TPA is an abbreviation for Third Party Administrator. These companies assist the health insurance companies with their back end processing of claims and are responsible for coordinating all aspects of claims arising due to health insurance policies.

These companies are licensed by IRDA (Insurance Regulatory & Development Authority) and enter into agreements with health insurance companies to provide them with support on claims administration and management. When you purchase a health insurance policy, the insurance company will inform you of it TPA and provide you with its contact details. In the case of hospitalization and associated claims, you will need to contact the TPA who in turn will assist you with the settlement of your claims.

TPAs will be your point of contact in case of both emergency as well as planned medical procedures and will provide necessary authorization to hospitals for ‘cashless’ treatments or in other cases coordinate with you for the settlement of claims for expenses incurred by you.

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The insurance company ties up with a group of hospitals for cashless claim process, and these hospitals then become a part of its “network”. When you avail of a cashless treatment in any of these network hospitals, the company would settle the claim with the hospital directly. A complete list of network hospitals is generally made available on the insurance company website or as part of the insurance documentation received at the time of purchasing a health insurance policy.

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A health card or a cashless card is issued by most health insurance companies and carries the details of your insurance policy. It is similar to an Identity card that can be used to avail cashless hospitalisation facility at the network hospitals of your insurer. The card will provide contact details of your insurer and Third Party Administrator (TPA) for you to contact in the event a claim is required to be made.

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A typical health insurance policy will cover expenses related to:
• Room and boarding expenses in case of hospitalisation
• Diagnostic expenses
• Surgeon, Anesthetist, medical practitioner, Consultant and specialist fees
• Anesthesia, blood transfusion, Oxygen, Operation Theatre expense, cost of surgical appliances, medicine and drug related expenses
• Pre and post hospitalisation expenses subject to terms and conditions as applicable to the product

Please read the products terms and conditions including coverage and exclusions as these can vary from product to product

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There are various illnesses which are not covered in the policy (commonly known as ‘exclusions’). This is entirely dependent on the type of policy and the insurer. However, the following are almost always excluded:
• Expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self injury
• War, riots, strike, nuclear weapon, induced treatment

It is important to review the exclusions clause of products at the time of comparing health insurance products or at the time of purchasing one to ensure that you know what would be available under your health plan.

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In all policies naturopathy is not covered. However Homeopathy is now being covered by some insurance companies, provided treatment is taken in a Homeopathic Hospital, which is empanelled with the insurance company.

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Traditionally Maternity / Pregnancy related expenses have not been allowed as expenses covered under Health Insurance plans and still feature as exclusions in most products. However, there are a few products that do cover maternity expenses subject to certain terms and conditions. These terms generally have a waiting period of anywhere between 4-6 years before maternity expenses being available under the insurance cover. This means that the maternity cover would only be available if you’ve had renewed your health insurance policy for the specified number of years stipulated as the waiting period. There is usually also a limit on the amount payable as claims under both normal and caesarean deliveries under these products.

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Health insurance policies do not cover hospital expenses incurred overseas. To cover yourself for any expenses that you may incur related to medical treatments or hospitalisation on account of an illness or accident while on a trip abroad, you need to have a Travel Insurance policy.

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While claims processes and documentation requirements vary from company to company, the following documents are typically required for filing a health insurance claim:
• Duly completed claim form
• Original bills, receipts and discharge certificate/ card from the hospital
• Original bills from chemists supported by proper prescription
• Receipt and investigation test reports from a pathologist supported by the note from attending Medical practitioner / surgeon prescribing the test.
• Nature of operation performed and surgeon’s bill and receipt.

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There is no limit on number of claims allowed during the year. The limit is on the overall Sum Assured or the insurance cover purchased with your health insurance policy. However, the coverage is reduced by the sum claimed by you with each claim. For e.g. if you have a health insurance policy with Rs. 5,00,000 as Sum Assured and you claim for expenses of Rs. 2,00,000, then the available cover for the remaining part of the year will be Rs. 3,00,000.

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Pre and post hospitalization means the medical expenses incurred during a period before & after hospitalisation for any disease / illness / injury sustained which is covered under your Policy. The period before and after hospitalization that is covered depends on the type of plan opted for. Generally, pre-hospitalisation expenses and post-hospitalization expenses are covered for a period of upto 30-60 days before hospitalization and upto 60-90 days after hospitalization respectively.

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When the condition of the patient is such that she/he cannot be moved to the hospital or when there is no bed available in any of the hospitals, the treatment is administered at the patient’s home. Importantly, the treatment is reimbursable under the health plan only if the treatment is comparable to that provided at a hospital or a nursing home. Generally, the duration of such treatment should be at least 3 days.

Usually, the limit of compensation is low and does not apply to certain diseases, such as asthma, bronchitis, diabetes, epilepsy, etc.

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Some products carry incentives (No Claims Bonus) for ‘claim free’ years and offer either an increased Sum Assured for no extra cost or a reduced premium for your Sum Assured.

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Most products do not allow an increase/decrease in the sum insured during the term of the policy; however at the time of renewal, you could adjust the Sum Assured according to your new requirements subject to the terms and conditions of the policy and your eligibility.

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You could lodge a complaint that you may have against any insurer relating to:

i. any partial or total repudiation (rejection) of claims by the insurance companies,
ii. any dispute with regard to premium paid or payable in terms of the policy,
iii. any dispute on the legal construction of the policy wordings in case such dispute relates to claims;
iv. any delay in settlement of claims and
v. non-issuance of any insurance document to customers after receipt of premium.
The contract of insurance is for an amount not exceeding Rs. 20 lacs.

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You need to lodge your complaint in writing addressed to the Insurance Ombudsman of the region under which the office of the insurance company falls. For a list of Insurance Ombudsman in India and their contact details including telephone numbers and email Ids please see the attached link. (http://www.irdaindia.org/ombudsmen/ombudsmenlist_new.htm)

You may lodge a complaint with the Ombudsman if:

  • You have already lodged a complaint with the concerned Insurance Company and it has either rejected your complaint or you have received no reply on your complaint within one month of your complaint or even if you are not satisfied with the response or action taken by the insurance company in respect of your complaint
  • Your complaint to the Ombudsman is not more than one year later after the reply of the Insurance company
  • Your complaint is not pending with any court, consumer forum or arbitrator.

 

The award of the Ombudsman is binding on the insurance companies but not on the complainant who can choose to approach other bodies such as Consumer forums or Courts of Law.

 

A detailed note on the functioning of the Insurance Ombudsmen in India is available on the Insurance Regulatory and Development Authority of India (IRDA) website. (http://www.irdaindia.org/brief12aug2003.htm)

 

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