Get your health insurance queries resolved by expert

Here you can find all the health insurance queries, our expert has responded to readers of the Financial Express newspaper.

I am 64 years and have an individual health insurance plan. I plan to undertake a cataract surgery. My insurer says it will pay a fixed amount which is half of the amount that the hospital will charge. What should I do?

This varies as per the product guidelines of the insurance firm. There are some who have a capping when it comes to procedures like cataract. There are some who apply a mandatory age-based co-pay at the age of 64 and there are some who honour the full claim without any co-pay. I would request you to refer to the terms and conditions document in your policy kit and understand the benefit better.

In case your policy is an individual policy with four members in it then your father-in-law can be added at renewals. In case it is a family floater, then you will have to purchase a separate policy for your father-in-law. Declare his pre-existing medical conditions while opting for this cover. He may be asked to undergo pre-policy medical check-up. Also check the applicable conditions like maximum entry age, co-pay, sub-limits.

This is kind of difficult as the maximum grace period generally allowed for renewing a health insurance policy is 30 days. In all probabilities you will have to opt for a fresh cover.

There are different kinds of co-pay such as mandatory co-pay basis entry age, voluntary co-pay, etc. The one which reduces premium is called voluntary co-pay where you agree to bear a per cent of the admissible claim and hence get the premium reduced as per the terms of the product. One takes a call on opting for voluntary co-pay, considering age, health status and possibility of claim etc.

As per the guidelines on Portability and Migration, all group insurance policy customers are eligible to migrate into a retail product offered by the same insurer. This migration, however, would be subject to underwriting. You should approach your HR team and establish contact with your group insurance provider and procure details at the earliest and continue to stay secured.

This is possible but subject to the product and underwriting guidelines of the insurer. However, in the current circumstances, where there is a chance of the whole family getting infected, continue with the individual policies as the coverage shall be available for every member.In floater plans the premiums are payable, generally basis the age of eldest insured member, which the younger insured may not find relevant.

Yes, you can pay your health insurance premium for a three-year term at one-go provided the insurance company has that feature available in their product. Whether paying for a two- or three-year term makes you eligible for a discount on premium depends on the product but in general, there is a long term discount available for two and three years policy tenure.

A family floater policy generally refers to self, spouse, two or three dependent children-. You can opt for a floater plan where your sister and her daughter are covered as insured members and your sister can be the proposer. You may also go for multi-individual policy where spouse, children, brother and sister, niece and nephew could be covered under the same policy with individual sum insured.

Yes. Portability is allowed under all individual indemnity health insurance policies issued by general insurers and health insurers including family floater policies. Wherein, the continuity benefits are offered on time-bound exclusion to the extent of the previous sum insured.

Usually, health plan bought in India do not cover any treatment outside India. However, there are a few high-end products which offer coverage outside India. Check the terms of your policy to see if treatments outside India are covered.

Discounts are based on the product you intend to buy. While many life insurance products offer discounts for online purchase given the long term policy nature, many health insurance products do not provide any discount.

This is a situation that is a byproduct of Covid-19 related logistic challenges. Irdai has taken steps to safeguard the policyholder’s interest. Hence, insurance companies cannot reject a claim merely on delay of submission of documents. In such a situation, the customer should give a valid explanation as to why the delay has happened. Based on it, insurer should honour the claim.

Of course you can. If coverage from one policy is insufficient to pay the bills then you can claim the remaining amount from another policy. The rule is that the same expense cannot be claimed twice from two different insurers.

It depends on the product / company where you and your family members are intending to be covered. Generally, in many products, the dependent children are covered till the age of 25 years. You may want to check with the prospective insurers and decide accordingly.

The child is mandatorily shifted into an individual policy when the child attains the age of majority as defined in the policy or if the child is no more dependent (becomes independent). Since the daughter is getting married, her dependence would shift from the existing family to the new family if the daughter is not earning. Continuity benefits are offered on such policies.

Employee group insurance does not have any pre-existing waiting period. So any hospitalization incidence would be covered from day one. In retail policy, a pre-existing waiting period is applicable. Retail health insurance can be renewed lifelong but group coverage ends when the employee exits the group and so the parents could be left without any insurance. Hence, take an independent retail policy for parents as well.

If there is any capping on certain procedures such as cataract, etc., the amount shall be paid as per the applicable sub-limits. However, super top -up which has no such sub limits and capping could be a good choice to cater to such out-of-pocket expenses.

Individual members including family members covered under an indemnity-based group health insurance policy have an option to migrate at the time of exit from group or in the event of modifica-tion of the group policy or withdrawal of the group policy, to an individual or family floater health insurance policy offered by the same insurer subject to underwriting. In this case, if you are currently not covered under any group health insurance policy, you may want to get you and your family covered under a new retail health insurance policy.

You may want to look at different covers for both of you as the age group and health issues are different. Some insurers have a restriction on entry age beyond 65 years. As you have been treated for a heart problem and your wife has a chronic condition, check with some insurers on acceptance as underwriting guidelines differ from insurer to insurer and product to product. Some insurers have certain plans for senior citizens with chronic health issues.

Policy premium depends on the features of the policy you have opted for. There are policies which offer room rent as a per cent of the sum insured, there are some which offer specific room category or even any room without any limitations as a per cent of sum insured. Policies which have capping on room charges also have optional covers to remove capping or enhancing the room category. It is better to have minimum restrictions even if it costs a little more premium.

It is important to opt for a health insurance plan at the earliest and not let any unforeseen hospitalisation claims eat up your hard-earned retirement savings. You should look for such plans where there are no restrictions on entry age. If you can afford the premium, considering your age, it is advisable to have a comprehensive cover with high sum insured. You can look for a plan which covers in-patient hospitalisation, day care treatments, pre & post hospita-lisation, ambulance, donor expenses apart from other health and wellness related benefits. Check for the sub limits and co-pay which can impact your claim pay-outs.

I would recommend a sum insured of Rs 10 lakh or more as a floater cover given the fact that in case one of you gets hospitalised then you have a sufficient cover at your disposal. Most insurers offer a restoration or recharge benefit in their core product proposition which works really well in a floater cover and acts as a backup for the family. Alternat-ively, you may increase the sum insured by purchasing top-up plan.

There are many plans available which gives the OPD cover. But while buying a plan, it is always better to go for compre-hensive cover which can take care of all kinds of health eventualities and not just dental or OPD related expenses. I have an office cover and a personal floater policy. Last month I had a bypass surgery and the total bill was Rs 5 lakh.

Of course you can. If coverage from one policy is insufficient to pay the bills then you can claim the remaining amount from another policy. The rule is that the same expense cannot be claimed twice from two different insurers.

Wondering how much coverage is enough to safeguard you and your family’s health?

Questions you should ask before making a financial commitment.

What am I buying?

Health Insurance is meant to protect your family’s financial future against uncertainty. It not only gives you a risk cover, but also empowers you to fulfill your various needs like:
1. Coverage against medical expenses -The main purpose of medical insurance is to receive the best medical care without any strain on your finances. You may, therefore, focus on your speedy recovery instead of worrying about such high costs.
2. Coverage against critical illnesses- Insurance providers nowadays offer critical illness insurance, either as a standalone plan or as a rider. This amount may be used to meet your illness-related treatment costs, daily expenses, and any other financial obligations.
3. Cashless claim benefit- Many insurance providers offer cashless claim facility.
4. Additional protection over and above your employer cover- You may be left uninsured in case of loss of job or change in employment. In order to protect yourself against such an event, purchase a health cover individually.
5. Tax benefits- Health care plans provide tax benefits. Premiums paid towards your health care policy are eligible for tax deductions under Section 80D of the Income Tax Act, 1961.

Your cover is the extent of protection that your loved ones will receive, simply put it’s the funds that your family will need to maintain their lifestyle in your absence. A few simple questions can help you find out what is the right cover for you.

  • How much of the family income do you provide?
  • How many people are financially dependent on you?
  • What are your current liabilities?

You will need to pay premiums, the amount that you invest for your policy, regularly for a specific time period known as the ‘Pay term’ which depends on the type of policy you purchase.
You can have Single Pay which requires you to pay a one-time premium or Regular Pay where you need to make multiple payments. A regular pay term can be monthly, quarterly, half-yearly or annual. Your pay term is different from your Policy Term which is the tenure of the policy.
Do determine the policy term and the pay term before signing up. Only commit what you are comfortable committing on an annual basis over the long term.

The sales brochures and other promotional material can help you understand the benefits of your policy, always ask for the policy literature provided by the insurer.

Your policy benefits depend on the type of policy you chose such as term insurance, or a unit linked insurance product.
It’s always advisable to read and understand the risk factors, terms and conditions of the plan. When in doubt ask your advisor to explain the details or contact the insurer.

Verify all the policy details before signing up for your policy. It is in your interest to provide correct information regarding your personal, medical and contact details to ensure smooth policy processing and a hassle-free claim processing in the long run. While filling the form, always remember to:

  • Check and fill the necessary details yourself and only then sign.
  • Ensure that your details match the KYC documents submitted by you.
  • Complete the nominee details and inform your nominees.

Always keep in mind the following:

  • Do not fall prey to promises of guarantee unless specifically mentioned in the product material.
  • No insurer can offer rewards or discounts on a policy purchase
  • Always check the advisor license if he has not been referred to you
  • Inducement to purchase insurance is illegal, in case you come across such instances immediately inform the nearest police station and lodge a complaint against the person.

Immediately check, to avoid surprises in the future!

What are the things I need to check immediately after receiving my policy?

Is my policy as per my expectations?

To ensure that you have received the policy that you expected, it is advisable to immediately review your policy document.
Check for some key benefits like Sum Assured, Policy Term, Premium amount & Pay term to ensure that it is as per your need. If you have any doubts, call the insurance company to enquire/confirm the same.

Accuracy makes for easy claim. Your policy document contains all your personal information, bank details, contact details and nominee details so do ensure that it is accurate and updated from time to time.
This will help avoid any confusion during the claiming process.

In case of an unforeseen circumstance, your family deserves utmost ease. Store your documents in a safe and accessible place and ensure that your nominees are aware of the policy details, benefits and all documents are easily accessible.
This helps in avoiding unnecessary delays and makes for a smooth claims process.

A few things that are important for you to practice are:

  • Keep a list of all the policies you own and standard claims practices along with your policy documents so that your nominees can find all information at one place.
  • Pay your premiums regularly; it will help you get the right benefit out of your policy.
  • Evaluate your cover every 5 years, just like your lifestyle – your cover needs an upgrade.

After Buying Policy

What are the things I should keep in mind as a policy holder?

How can I ensure that I get maximum benefit from my policy?

Insurance benefits you only in the long-term. It is also important that you pay premiums regularly to enjoy benefits. Missing a payment may leave you without health insurance cover and also the benefit of tax saving.

If you lose your policy document, report it to the insurance company immediately. You can get a duplicate policy by complying with the formalities. The duplicate policy confers the same rights as the original policy document.
If you are unable to pay the premium in time, your policy may lapse. You can contact the insurance company through your advisor or directly for reviving it. It is always advisable that you revive your policy and continue to enjoy its benefits.

As a policy holder, you should know the following:

  • Your contact details must be updated with the insurer so that you can be reached for any service offerings and communication.
  • Your nominee details must be updated at all times so that the insurer can ensure a hassle free claims experience for your family.
  • In case your agent is not being responsive to your queries and requirements, you always have the option of contacting the insurer directly.
  • You must evaluate your protection cover every 5 years, as your cover needs to keep pace with your increasing responsibilities.

Don’t fall prey to temptation/inducements/hoaxes/threats without checking the truth behind calls/claims. Here are a few things you should know:

  • No insurer can offer rewards/discounts on giving up your policy for another one.
  • Surrendering your policy is never a good idea if someone is offering you a reward or inducement.
  • Cross - check any suspicious refund calls or policy replacement with your insurer.

Please note that IRDA or an insurer would never make calls for additional benefits, declaring bonus, surrendering policies etc.
Do not believe such fraudulent calls, always cross-check all scheme related information and benefits either on the company’s website or by visiting the branch.
In case you receive such calls, immediately lodge a complaint by calling your insurance service provider with the details of the caller (phone number, name of the caller etc.)