FAQ ON HOW TO MANAGE YOUR HEALTH INSURANCE POLICIES
MANAGE YOUR HEALTH INSURANCE POLICIES
The FAQ Section on managing Health Insurance is authored by Sri R.Vijayaraghavan
Shri R.Vijayaraghavan B.Sc , CAAIB is a retired Senior Manager of IOB. He is a very prominent Banker , with a strong domain knowledge in General Banking, Advances , Forex , HR Development , Staff Training , Audit , Inspection, Risk Management and Wealth Management. He is very popular for his “Notes on Banking “ which serves as a ready made guide for Supervisory Staff Promotion in Banks for all grades. For the last three decades he was helping the Banking Community by sharing his valuable reading materials as a free service.
We thank Mr Vijayaraghavan for this contribution .
REGARDING DISCLOSURE OF PRE- MEDICAL CONDITION :
1. Care should be taken to make a full disclosure on the health of insured with full medical history, details of existing diseases, medicines treatment undergone etc.
2. Details of any other existing insurance cover should also be disclosed. If the columns are not sufficiently spaced,attach a separate paper with all the above particulars ,duly mentioning that existing diseases are fully disclosed in the enclosed sheet/s ( mention number of sheets attached, in the application form)
3. Keep a Xerox copy of the application form mentioning the details
, if possible with the acknowledgement from the Insurance Company.
WHAT TO DO ON RECEIPT OF INSURANCE POLICY ?
How one should examine the new policy received for descripancies , details and important points to comply with ? .
1. Check -Whether Name , age , DOB is correctly mentioned in the policies for all the insured persons.
2. Check the amount of premium is correctly mentioned.
3. Check the period of cover and the amount of cover.
4. Check the exclusion clause to ensure nothing is added more than what is specified in the initial terms and conditions , during the offer.
5. Check the Co pay clause, Sub limits and other deductibles are as agreed.
6. Check the particulars are correctly mentioned in the id cards also.
7. If there is any discrepancy bring it to the notice of the Insurance Co immediately by email or through web or mobile app.
Note down the important contact numbers, claim form and procedures and if possible down load the app of the TPA.
WHAT ARE THE DOCUMENTS TO BE KEPT HANDY TO TACKLE INSURANCE NEEDS IN CASE OF MEDICAL EMERGENCY ?
Following Documents for Self and Spouse to be kept in pouch :
a. Health Insurance id card –Original and Xerox.
b. Aadhaar card- Original and Xerox.
c. Pan Card-Original and Xerox.
d. Employee/Pensioner Id card-Original and Xerox.
e. Brief Medical History- Current Medicines/Health Condition, Treating Dr Contact No, Allergies if any etc.
f. Copy of Policy or Receipt indicating the insurance amount and period of cover.
g. Details of Other policies/Super Top up Policies if any.
h. Brief Claim history for the current period , if any, with cover balance available.
ON CASHLESS FACILITIES :
For Cashless treatment , in case of planned hospitalization , what are the important points to be noted while getting the estimate for treatment?
Total cost of treatment depends upon the room rent and all major hospitalization costs like Surgeon fee, Nursing and other treatment costs are linked with per day room rent only. It is better to get the estimate for different type of rooms and decide the room category , depending upon the future need and available cover.
Whether cashless facility can be availed with out Id card( Physical)?
Yes. It can be availed with e card that can be downloaded from the website of TPA.
ON TOP UP AND SUPER TOP UP POLICIES :
What is the difference between Top up and Super Top Up Policies?
Top up plans work on ‘per single hospitalization’ or :per claim” basis. A Top up plan will pay you, if your claim amount for a single hospitalization is above the threshold limit. They are beneficial as long as the single claim amount is above the threshold limit.
Where as Super Top up plans consider ‘the total of all the bills’ in a given year. Super Top up plans cover ‘multiple’ hospitalizations and they look at the aggregate claim.
Example – Mr x has a personal Health Insurance policy of Rs 3 Lakh and also has a “Top up” health cover of Rs 10 Lakh sum assured, with the threshold limit of Rs 3 Lakh.
Scenario – If there are two claims in a year, one for Rs 3 Lakh (Claim 1) & another for Rs 2.5 Lakhs (claim 2), regular policy will pay the claim 1 amount (Rs 3 Lakh) and the total coverage is exhausted, the claim 2 amount (Rs 2.5 Lakh) is not covered by regular as well as the top up plan. (Though he has Rs 10 lakh as a top up cover, it is not applicable for 2nd claim as the threshold limit is Rs 3 Lakh. Top up cover will pay only if the bill amount is more than Rs 3 Lakh). Where as In Super Top Up Policy this is possible. In Super Top up Multiple claims are allowed and once the basic policy is exhausted, Super Top up policy would trigger in for subsequent claims even if they are lesser than the basic policy amount.
Example – Mr x has a personal Health Insurance policy of Rs 3 Lakh and also has a Super Top up health cover of Rs 10 Lakh sum assured (total coverage Rs 13 Lakh), with the threshold limit of Rs 3 Lakh.. Scenario – If there are two claims in a year, one for Rs 3 Lakh (Claim 1) & another for Rs 2.5 Lakhs (claim 2), regular policy will pay the claim 1 amount (Rs 3 Lakh) and the total coverage is exhausted, the claim 2 amount (Rs 2.5 Lakh) will be paid by his super top up plan (though the claim 2 amount is less than the threshold limit).
Whether in Super Top Up Policies Cover Pre and Post Hospitalization Expenses?
It depends upon the Terms of the policy. Unless Specifically excluded, Pre and Post Hospitalization expenses are too covered. Question: What are the expenses normally covered in Super Top Up policies? It depends upon the Terms of the policy. Super Top up Policy covers the following as covered in the base policy , unless specifically excluded in the terms of the policy.
1) Normally Hospitalization expenses covers Pan India occurred either due to accidental or natural diseases.
2) In patient hospitalization expenses will be covered on reimbursement basis.
3) Additional Medical test/s, normally not required, prior to taking up Top up policy .
4) In some policies, 1 Month Waiting Period is applicable under the policy for hospitalization claims.
5) 30 days pre hospitalization expenses are included: Medical expenses incurred 30 days prior to the hospitalization are reimbursed.
6) Normally , depending upon the terms of the policy, Post Hospitalization expenses up to 60 days are covered.
7) Internal congenital diseases covered.
8) Minimum Hospitalization of 24 hours required for the treatment, which cannot be taken at home.
9) The minimum hospitalization clause is not applicable for Cataract, Chemotherapy & fracture or any Day Care treatment.
FOR HOLDERS OF MULTIPLE INSURANCE POLICIES :
When the Policyholder is having coverage from multiple Insurance Companies:
The earlier position was the claim settlement will be done /shared by the two insurance companies in proportionate to policy amount. For eg if a person is having two health insurance policies for Rs 4 lacs and Rs 1 lac from two different insurers( A & B) and if the claim is made for Rs 2 lacs, Rs 1.6 lacs to be settled by A and Rs 40,000 by B. This is called contribution clause .
After the introduction of IRDA(Health Insurance) regulations 2013 the position of Contribution clause is changed. As per IRDA latest guidelines ,if the insurer is covered under two policies from different insurers, there is no paripassu / contributory clause if the claim amount is well with in any one of the policy amount . The insured has the right and prerogative to claim from the insurance company of his choice.
Now the contribution clause will not be applicable if the claim amount is less than the sum assured of the insurer where the claim is made.
However , if the claim amount is above the sum assured of the policy, then the insurance company will impose the contribution clause. Policy holder is free to choose which insurer to make the claim.
While making Claim the details of the other insurance plan has to be mentioned .
In such cases policyholder make a claim with one insurer and mention the details of the other health plan. The insurance companies have a contribution clause in place, where each company has to share the claim based on the proportion of the sum assured for the same claim.
"If the amount of claim exceeds the sum insured under a single policy after considering the deductibles, co-pay, the policyholder shall have the right to choose insurers by whom the claim should be settled, In such cases the insurer may settle the claim with contribution clause," state the Health Insurance Regulations, 2013.
In such cases one should submit all the hospital documents to the first insurer and submit attested copies or certified duplicate bills to the other insurer for the balance amount.
MISC QUESTIONS :
or Hospitalization , for reimbursement claim , how soon the TPA should be intimated?
As a general rule with in 24 Hours or prior to hospitalization. Claim to be submitted with in 30 days of discharge.
On every Renewal of Group Insurance Policy, whether New Id card will be issued?
The Id card issued at the time of commencement of policy is valid as long as there is no change in the policy conditions and also if there is no change in TPA.
DISCLAIMER :
The answers provided by the author and the opinions expressed are general in nature and provided to help the readers to understand the subject. The readers are requested to read the Terms and Conditions of the Contract and policies ,before acting upon individually. The Author is having no beneficial interest on the views expressed and accepts no responsibility for any action based on it.
To help you to contact your insurer for any particular question on the health insurance policy you hold , we have provided the list of websites of the insurers in India . The website takes no responsibility on the opinions expressed by the author .