Health insurance provides financial security to meet the costs incurred as a result of hospitalization or treatment of a particular disease. It is a signed agreement between the insurance company and the policyholder.
The company or insurer agrees to provide the allowable amount or amount of coverage to the insurer (insurer) to cover medical expenses. To receive this benefit, the insurer must pay a certain amount of money in the form of a premium.
However, not all types of cases and cases are covered by health insurance. This is called a discharge. Let's take a closer look at health insurance.
What is a Health Insurance Premium?
To get financial protection under the health insurance scheme, you need to pay a certain amount of money annually in the form of a premium. This can be called the cost of insurance. A premium is an important factor to consider before finalizing a plan.
Always use the premium calculator available on the insurance company's website or web insurance aggregators to determine the premium amount. This helps to compare different programs and measure your purchasing power.
Some of the factors to consider when deciding on a premium are:
• Type of insurance plan: The health insurance scheme premium depends on the type of plan chosen. It varies from family to family and from personal plan
• Type of job applicant: The nature of your job continues to determine the amount you pay. If your type of work is risky, you will pay a higher premium amount. For example, the job of a truck driver is more dangerous than that of a teacher. Therefore, the driver will pay a higher fee compared to the teacher
• Age: With access to a health insurance plan, age is an important factor. Therefore, it also determines the premium value. The higher the age, the higher the premium rate, as older people are more likely to suffer from any illness
• Current medical condition: Any medical history or rather the current medical condition of a person plays an important role in determining the amount paid. In the event of a pre-existing illness, the premium may increase
• Number of family members included: With each health insurance plan, you get coverage for more than one family member. Therefore, the premium amount depends on the number of family members included in the plan
• Policy duration: The period of health insurance determines the amount paid. Therefore, if the plan is long-term, the premium amount will automatically increase.
Types of Health Insurance Policies
Health insurance is available in a variety of forms. However, all health insurance policies can be broadly divided into two types: an Indemnity policy and a fixed benefit policy. Let us consider these two aspects in more detail.
This plan covers the cost of hospitalization up to the limit determined at the time of purchase policy. An insured person may choose multiple claims per year, but the total amount provided should not exceed the total amount of insurance money or the amount you should receive from the insurance company. This type of plan is also known as Mediclaim policy. You also have the benefit of receiving non-cash treatment at various network hospitals, for which the insurance company pays you.
Types of Indemnity Policies
1) Individual Insurance schemes: This type of health insurance is for individuals. Therefore, the insurance provider only looks at the medical costs incurred by the individual. The medical costs incurred in these programs usually cover all costs incurred in hospitalization, before and after admission, the costs of various medical examinations and laboratory expenses, and consultation costs.
Since this cover is for personal use only, premiums are cheaper than other plans. These individual drug policies do not include any existing diseases. However, after waiting a while, these diseases can be covered by the insurance company. Most insurance policies do not include ayurvedic, homeopathic or other non-combat therapies.
2) Family Care Insurance Systems: These types of insurance plans cover the whole family. Instead of buying separate individual plans, you can get a family flat that will cover the medical and medical expenses of all family members. These plans include the policyholder, spouse and children. Children under the age of 2 can also be covered under this program.
Other programs include siblings and in-laws. Family apartments can provide health coverage for up to 15 relatives in one program. Therefore, all family members share the money covered by the insurance.
3) Older Citizens Insurance: These insurance plans cover the cost of treatment or accommodation for people aged 60 or older. Illness and other health-related problems after 60 years are common. Retirement can also deprive people of any normal income. In such a case, bearing the cost of medical treatment may be quite a burden.
Therefore, older health insurance schemes can help meet medical expenses in an emergency. The IRDA is required by the policyholder to be at least 60 to 65 years old when applying for the policy. Some insurance companies also offer medical tests before approving a policy. The waiting period for these policies may range from 1-4 years in the event of any illness.
4) Maternity Insurance: Pregnancy Insurance schemes are designed for women who are planning to have a baby or give birth. It covers all costs before and after pregnancy, child-care expenses, maternal care costs, and any problems that may arise as a result of the pregnancy. Such a plan can be added to the main policy of Individual or Family Floater.
In addition, it can be linked to Group Insurance programs offered to employers with limits below Rs. 50,000. All costs associated with testing, medication, labor, and admission can be reduced by taking this program.
Any emergency evacuation due to complications related to pregnancy, delivery costs, nursing, and consultation are also included in this program. It includes a congenital defect or a serious infection in the newborn.
The waiting period is up to 4 years, as only after that can all benefits be realized. So it is a good idea to buy this program well before you get pregnant. Excludes include the cost of regular checkups, diagnostic tests, and consultation fees, as well as any medications such as vitamins, during pregnancy.
5) Medical/employee group insurance: Group Medical Insurance is provided by employers for their employees. Groups under this policy include members of any organization, companies, etc. In addition, by paying more, employees can also extend the program to include other family members such as partners, children, parents, etc.
As with other programs, tax premiums under this scheme are tax-free. Other policies also include existing illnesses and maternity costs. Unlike other programs, to purchase this program, employees do not need to produce any documents or perform medical tests. Also, premiums are cheaper here. The plan can have an impact, where employees also pay a portion of the premium, or non-contribution, where only the employer pays the premium.
B. Fixed Benefit Policy
This program does not offer the benefit of hospitalization. It pays a fixed amount for certain serious diseases listed and conditions, such as cancer, heart disease, etc. Under this program, a person also gets diagnoses for certain diseases.
Types of Fixed Benefit Policy
1) Preventive insurance: The protective health insurance program covers the cost of regular medical check-ups needed to prevent any serious illnesses such as cancer. With this, annual clinical trials may be needed to assess potential symptoms. Such plans may provide coverage for any tests performed at an insurance network hospital.
Costs also cover all preventive measures taken by the policyholder, spouse, children and parents. Children under the age of 13 are protected under this policy. Unlike other programs, this program includes tests related to HIV / AIDS, cancer and cholesterol.
2) Critical Illness: Critical illnesses are diseases that are not included in health insurance plans. These are just some of the conditions that can lead to permanent disability or death. Some of the diseases covered by the program include cancer, organ transplants, and failure, multiple sclerosis, paralysis, blindness, stroke and heart attack, kidney failure, coma, critical heart surgery, among others.
This policy provides a lump sum for the treatment of these diseases. This policy can be purchased separately or as a supplement to a life insurance plan. Under such a scheme, if the policyholder is found to have any serious diseases listed within a period of time, you will receive the application benefit and other benefits.
Some companies also offer a daily allowance benefit because the policyholder is unable to work and earn an income due to illness. Such programs often have a low waiting time.
3) Daily Hospital Benefits: Provides planned benefits, usually after 24-48 hours of hospitalization. Covering is in addition to the benefits offered by the health insurance system. This plan covers costs that are usually not included in the health plan. You get a fixed amount every day while you are hospitalized.
4) Personal Accident: The plan provides for accidental death and disability and the permanent residency of the policyholder. Such a policy could be a good addition to car insurance to cover death or physical injury to a driver.
In the event of a sudden death of the policyholder, the plan also provides a guaranteed amount to family members to take care of various expenses and needs. No medical documentation required to purchase this policy.
It can be found for both individuals and groups. Also, many policies cover all legal and funeral expenses without covering any injuries caused by terrorist attacks.
Personal Accident Cover can be divided into 2 types:
Individual Accident Cover: The program covers an individual's disability, paralysis or death as a result of an accident.
Group Accident Cover: Provided by employers to cover the employee's family expenses for his or her sudden death.
Most health insurance companies that provide health insurance in India offer coverage to people under the age of 45 without medical examinations. They can ask for details of any pre-existing conditions such as diabetes or high blood pressure. However, those over the age of 55 need a medical examination.
Coverage of Health Insurance Policy
Health insurance companies offer a wide range of plans and policies to choose from according to your need and requirement. You need to understand the coverage well before choosing a particular program and policy. Let's take a look at some common points covered by the various programs offered by health insurance companies.
Pre-hospital and post-hospital expenses: This insurance covers medical expenses incurred between 30 and 60 days prior to hospitalization. This covers things like drug costs and medical tests, etc. This is in addition to the usual availability such as meeting the cost of accommodation for at least 24 hours, rental room, operating expenses, etc. 180 days after hospitalization such as medication, home treatment, etc.
Ambulance Fee: Almost all health insurance schemes cover costs associated with ambulance service.
Suncare cases: Some of the health insurance schemes also cover medical expenses incurred without hospitalization for up to 24 hours. This includes cases such as dialysis, radiotherapy, chemotherapy, etc. Health screening: Some health insurance companies also pay for preventive health screening costs.
Procedure to Claim Health Insurance
A health insurance policy helps manage any unforeseen medical expenses. Therefore, in the event that something happens, you need to file a claim in order to make a profit. There are two types of claims: cash claims and refunds.
Cashless Claim: To get this kind of claim, you need to use one of the network hospitals, which is a hospital provided by an insurance company. Here, the policyholder does not have to pay for hospitalization as it is borne by the insurance company.
Let's understand the claim for free.
• In the case of scheduled treatment, inform the insurance company in advance. This can be done via email or a toll-free number
• When you are hospitalized, give the health card provided by the insurance company to the hospital's Third Party Administrator (TPA) table and permission from the treating physician
• Also send the required documents
• If the insurance company has pleaded guilty, it pays the medical bills directly to the hospital
Claims for Reimbursement: Here, the policyholder makes a payment for treatment and hospitalization. However, you refund the money over time in the amount of money deposited after submitting the required documents.
Let's understand the refund claim process.
• After paying your medical bills yourself, send the bills and other documents needed by the insurance company
• After the test, if the insurance company finds the application to be valid, it will pay to the insurer
Documents Required for Processing Claims
For claims to be made in a timely manner, certain documents are required.
• Complete the application form in full
• Medical certificate from a doctor
• Release summary
• Investigative report
• Pharmacy bills
• BLOW (in case of accidents)
Note: This is not an exhaustive list.
Time Taken to Resolve Claims
Upon receipt of a claim, the health insurance company usually takes 30 days from the date of receipt of the claim to pay the claim. However, if there is any kind of investigation required to process the claim, it usually takes 45 days to pay the claim from the time the documents are received.
Not Covered in Health Insurance
Health insurance offers a wide range of medical expenses, treatments and diseases to help you manage your finances better. However, certain circumstances and charges are not covered by health insurance schemes, although the list varies from one provider to another. Always understand this release before completing the program so that you do not face problems over time. Let's take a look at some unusual ones.
• Dental treatment, including surgery
• Treatment of AIDS and other sexually transmitted diseases
• Non-allopathic treatment
• Some existing diseases and serious illnesses
• Maternal pregnancy or the birth of newborns
Note: This is not an exhaustive list.
List of Companies Provides Health Insurance Policy in India
Before graduating from a particular health insurance company and program, it is important to keep certain points in mind so that we can better understand the policy. Let's look at some of the features.
Claims Resolution (CSR): This is the percentage of claims that have been resolved compared to the percentage of claims received. Always look for a company with a record of high claims. This way you will be sure that your claims will be resolved smoothly in a timely manner.
Limitations: Understand boundaries and caps in certain areas such as renting rooms so you know how much you have to bear.
Reading: Specify the coverage offered in the program so you know if your needs and requirements are being met or not. For example, some plans do not include non-allopathic treatments.
Waiting time: For some existing illnesses, some insurance companies have a waiting period of several years before they are covered by the plan. Know these diseases before buying a plan.
Network Hospitals: Choose an insurance company that has a good number of network hospitals to get a free claim site if necessary and you do not have to pay in your pocket.
Benefits of Purchasing Health Insurance Policy
Health insurance forms an integral part of a person's portfolio. Let's look at some of the benefits of insurance:
• The health insurance plan helps to manage unexpected medical expenses or hospitalization costs that have the potential to disrupt your budget and create a financial burden
• The program helps to manage the rising medical costs
• Provides peace of mind when the financial burden is taken care of by the insurance company during those stressful times
• Treatment in-network hospitals provide a free environment
• It helps to save taxes.
• Health insurance premiums are tax-free up to a limit of Rs 1 lakh under Section 80D of the Income Tax Act, 1961
• For people under the age of 60, the maximum amount you can save tax is Rs. 25,000. This is true even if you are paying for your spouse and dependent children
• For persons over 60 years of age, the limit is Rs. 50,000
• The tax exemption limit is Rs. 50,000 parents over the age of 60
• If the tax and parental tax years are 60 years or more, the exemption limit is Rs. 1 lakh