The guide to choosing the health insurance you need

However, many policyholders believe that insurers are required to pay their claims in full. This is not the case however. Insurers only settle claims based on the terms and conditions stated in the policy document. Moreover, they adhere to a prefixed rate recommended by the General Insurance Council (GIC) in India when settling such claims.

Here are some ways that can help you get the most claims out of your health insurance policy.

Global health policy: Most health insurance policies come with a deductible, commonly referred to as super supplemental plans. In these plans, there is a threshold limit (deductible) on the payments. Before your health insurance policy fully covers your medical expenses, you must reach this threshold.

Depending on your plan, your annual deductible may be a few thousand or even thousands of rupees. In other words, a super add-on plan generally works on a cost-sharing basis. This means that the plan does not bear the entire cost; only a part is covered depending on your deductible.

However, a comprehensive health insurance policy covers all types of medical expenses without any deductible. It covers a wide range of medical costs, including hospitalization costs, etc., without the insured having to pay them out of pocket.

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Multi-annual health policy: When you purchase a multi-year health insurance policy, the premium stays the same for the duration of the policy. This way you are protected against any subsequent premium adjustments made by an insurer during the term of the policy. As a rule, policyholders have to pay multi-year premiums up to three years in one go. Thus, an increase in the cost of insurance will not affect you for three years.

Prawal Kalita, managing director of Marsh India, said healthcare costs were on the rise. A distinct advantage that a multi-year contract offers is the locking in of the premium that one obtains by opting for such a policy. “However, you have to weigh the financial and practical gains of multi-year policies when choosing them,” Kalita said.

Terms and conditions: Insurance documents offer a detailed explanation of the terms and conditions of the policy that can span multiple pages, whether purchased online or offline. Most policyholders avoid going through the documents because they are too long, which can prove costly during the claims process.

Room rental clause: Some expenses are unavoidable if you are hospitalized and these include fees paid to surgeons, consulting physicians, medical bills and operating room fees, etc. Most of them are fully covered by your health policy, except for the fees paid for the service or the room you are admitted to. Insurance policies set a limit to the costs that can be paid for this. If the insured occupies a room whose rent is higher than what is mentioned in the insurance policy, this may lead to deductions from the amount of the claim.

Ankit Agarwal, CEO and co-founder of InsuranceDekho, said most insurers usually allow basic standard or individual private rooms as part of a health insurance policy. “You should always opt for a room whose rent respects the limit set by the insurer. Otherwise, you can also opt for a policy with no room rent sublimit or choose to opt for additional coverage for an additional fee. It is essential to check the room rent limit in a health insurance policy,” Agarwal said.

Co-payment clause: This is a clause in the policy in which insurers agree to pay a prefixed percentage of the claim amount since most health insurance policies do not cover certain expenses.

Agarwal said, “You should choose a health insurance policy that does not have a co-payment clause. In addition, health insurance policies generally do not cover costs associated with maternity, dental and optical examinations or treatments. It also does not cover treatment resulting from the consumption of intoxicants, voluntary organ donation, etc. In some cases, it is a good idea to opt for additional guarantees. For example, you can add maternity cover to your policy to meet maternity-related expenses.

Complaints process: No insurance policy can achieve its purpose until it provides the insured with adequate claims settlement. Indraneel Chatterjee, co-founder of Renewbuy, said: “There is a serious question around the settlement of claims carried out by the traditional branch-led model, even today. It is better to opt for a cashless facility when it comes to settling health claims.”

“As a rule, insurers have a link with the hospitals in the network. Because of this affiliation, they manage to offer discounted rates for frequent treatment to policyholders if they file cashless claims. Insurers and hospitals in the network only offer discounts on cashless treatments as it helps them manage the costs of claims for multiple scheduled surgeries,” said Abhishek Bondia, Senior Director and Managing Director of SecureNow.in.

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