Health Insurance

Health Insurance Terminologies

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Explained below are terms that you must know in order to understand your health insurance better:

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• AYUSH: Ayurveda, Yoga and naturopathy, Unani, Siddha, and Homoeopathy, are the kind of treatments that are covered under AYUSH. There are a number of health insurance plans that provide coverage for AYUSH.

• Bariatric Surgery: Treatment or surgery related to weight loss is called Bariatric surgery. So, if you are planning to undergo weight-loss treatment, make sure that your health plan provides coverage for Bariatric Surgery.

• Base/Indemnity Plan: A base or indemnity plan is one in which the health insurance claim amount is paid out based on the actual medical expenses. For example, if you have a sum insured of Rs. 10 lakhs and the hospital bills are of Rs. 8 lakhs, then Rs. 8 lakhs will be directly settled by the health insurance company.

• Critical Illness: Critical illness refers to life-threatening diseases such as cancer, stroke, kidney failure, and others. There are plans that provide coverage for critical illness at additional costs, thus it is important to check the same while you are buying health insurance.

• Claim: The term refers to the request made by the policyholder to the insurance company to compensate for the medical expenses. Policyholders can claim their policy in two ways; reimbursement claims, and cashless claims. Cashless claims are directly settled by the insurance company at the network hospital where in case of reimbursement claim, the total amount is later reimbursed by the insurance company.

• Co-Payment - Health plans compensate you for healthcare expenses incurred during a treatment that is covered under your policy. However, co-payment occurs when the insured and the insurance company share the expenditures at the time of the claim. In general, health policies with a co-payment clause have lower premiums. This feature is most commonly found in senior citizen health insurance plans.

• Daycare Procedures: Daycare procedures are those that require hospitalisation of less than 24 hours such as chemotherapy, dialysis, and more.

• Domiciliary Treatment: There are times when a policyholder seeks treatment from a medical professional instead of going to the hospital. Such a treatment which can be availed at home is called domiciliary treatment.

• No Claim Bonus - It is a reward that a health insurance company gives to the insured for not making a claim in a particular year. For instance, an increase in the sum insured by a fixed percentage according to the policy, not more than 50% of the sum insured, if the policy has been renewed continuously.

• Deductible - Deductible is identical to co-payment. It is a fixed amount in rupee terms that are shared by the policyholder, and not the insurance company, at the time of claim. It is, however, decided by the insurance company if the insured is required to pay this amount per year, per life, or per event.

• Dependents - Family members including legally wedded spouse, unmarried children, and more who are financially dependent on the insured are known as dependents.

• Exclusions - There is an innumerable list of conditions that are not covered under the health plan during the policy tenure by insurance companies. Hence, these leftovers are known as exclusions. Some common exclusions under health insurance are treatments required due to participation in adventure sports, Injuries due to self-harm, insured committing a breach of law, etc.

• Grace Period - The grace period is a specific period of time that is given to the policyholder to pay the premium to continue availing coverage benefits under the policy, immediately after the expiry of the due date or premium payment. Hence, if you will pay the premium during this period, then you can continue to avail the policy benefits. However, in case you forgot to pay your premium during the grace period also, then your policy may lapse and you may lose all the accumulated benefits.

• Insurer - The insurer is the insurance company from which you choose to buy the relevant health plans and get protection for yourself and your family.

• Premium - A fixed amount that must be paid on a regular basis in order to continue receiving benefits from your health plan.

• Policy - It is a legal contract between an insurance company and the insured, that contains all the terms and conditions of the insurance.

• Pre-Existing Disease - Any condition, illness, or accident for which the insured had symptoms within the past 48 months before purchasing a health policy falls under this category. After a certain waiting period, pre-existing conditions are often covered by the policy. Therefore, it is advised to report any pre-existing conditions in order to prevent complications at the time of claim settlement.

• Network Hospital - Network Hospitals are referred to those medical care centres that have a partnership with an insurance provider and are entitled to pay cashless care to the insured. To ensure maximum ease in the event of an emergency, it is advised to select an insurance carrier with a large number of network hospitals.

• Portability - In case the insured is dissatisfied with their existing company or policy, they can either switch from one company to another or maybe change their insurance plan to another. The portability feature can only be availed of if the insured has maintained their plan without any lapse. Portability allows you to transfer the accumulated benefits as well such as waiting for period benefits, NCB, and much more.

• Restoration Benefits: Restoration benefits refer to the situation when the exact sum insured is automatically restored even after the policyholder has raised a health insurance claim.

• Riders: Riders or add-ons refer to additional benefits given to the policyholder. Some of the add-ons that you can include in your health insurance plan are critical illness rider, hospital cash, rider, maternity rider, and more. However, policyholders need to pay extra premiums to include these riders in their health insurance plan.

• Room Rent Limit: It refers to the limit up to which the insurance company pays for the hospital room. If the room expenses are beyond this, then the policyholder will have to pay the remaining money from their pocket.

• Preventive Health Check-up: Preventive health check-up refers to the benefit given to the policyholder in which the insurance company assesses the health condition of the policyholder for free.

• Super Top-up: A super top-up plan is one which can be added to a base health insurance plan to further enhance its benefits. It is ideal to expand the scope of health insurance coverage.

• Sum Insured - It is the sum amount that an insurance provider is liable to pay to the insured at the time of claim. For instance, if a health insurance policy's sum insured is Rs. 5 lakh and hospitalization costs total Rs. 2 lakh, the insurance company will pay the costs. However, the insured will be responsible for paying any additional costs if the expenses are greater than the maximum sum insured.

• Underwriting: This is the process during which the health insurance company assesses the health insurance application request. Based on the medical condition, the insurance company will set the health insurance premium that needs to be paid by the policyholder.

• Waiting Period - This is a fixed time period for which the medical insurer does not cover you, even after the commencement of the policy term. Waiting periods can be of different types such as initial waiting period, waiting period for specific diseases, waiting period for pre-existing diseases, etc. The waiting period is calculated from the date of commencement of the policy.

• Free Look Period - It is the time period in which the insured can understand all the details, features, benefits, terms, and conditions of their policy. During this period, if the insured is not satisfied with their plan, then they have a choice to cancel the policy.

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Waiting Period In Health Insurance

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Even after purchasing a health plan, insured is not entitled to receive the entire value for some conditions that are mentioned in your policy due to a waiting period in health insurance. Hence, this means that insured person will only be eligible to get coverage benefits for pre-existing diseases after completing a specific time-period, which is determined from the beginning of the policy.

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Types Of Waiting Period In Health Insurance

Following are the types of waiting periods:

1. 1. Initial Waiting Period: Initial period, that is also known as cooling period, is that in which the policyholder has to wait for a certain number of days before receiving any claim benefits under the plan. Most of the health insurance plans come with a waiting period of minimum 1-month and maximum 90 days.

   2. Pre-Existing Diseases (PED) Waiting Period: It is a pre-existing disease waiting period that the insured acknowledges at the time of policy purchase. According to the Insurance Regulatory and Development Authority of India (IRDAI), a pre-existing disease is defined as any condition, accident, ailment, or disease detected within 48 months of the policy acquisition. Pre-existing illnesses include thyroid, hypertension, and diabetes. Pre-existing conditions are usually subject to a 1-4 year waiting period in most health insurance coverage.

   3. Waiting Period for Specific Diseases: There are some conditions, including hernias, tumours, ENT disorders, cancer, strokes, and cardiac problems, that come with a specific waiting period. This period for specific diseases vary from insurer to insurer and can found in the policy provision of each company.

   4. Maternity Waiting Period: If you are planning to start your family very soon, then you can add maternity coverage to your standard health policy. With this plan, your pregnancy expenses and a newborn baby care cost will be covered. However, a policyholder can avail benefits only after the waiting period of 2 years to 4 years.

   5. Waiting Period for Bariatric Surgery: Under a variety of health policies, bariatic surgery is also covered. It is a procedure that involves stomach or intestines surgery done to assist a patient with severe obesity-related disorders. The individuals who are experiencing health problems and are with a BMI of over 40 usually undergo bariatic surgery.

   6. Waiting Period for Coronavirus: Many people in India are purchasing coronavirus specific health plans for themselves and their loved ones because of the increased frequency in the number of cases and a high treatment cost. However, insured must have to wait for 30 days before receiving coverage benefits such as hospitalization and therapy under these plans.

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What Is The Importance Of Waiting Period In Health Insurance?

The purpose of a waiting period is to prevent people from claiming benefits under a policy for the wrong reasons. People without health plans have purchased plans after being given a specific diagnosis, often without disclosing the diagnosis to the insurance company. The concept of a waiting period is also included in health policies to stop unethical behaviour like this.

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How To Calculate Health Insurance Premium Online?

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With the help of health insurance premium calculator, you can easily estimate the value of your health plan or medical insurance policy. The online tool will calculate the premium on your health plan without any hassle. Moreover, it is a free tool through which you can compare a variety of available plans to choose the most suitable for yourself as per your requirements and budget.

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The premium is calculated after considering various factors such as BMI, age, lifestyle, income, gender, no. of members to be covered under the plan, and many others. Hence, to avoid any discrepancy in calculating the premium, it is advised to provide the correct details.

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Following are the steps to be followed in order to use health insurance premium calculator online:

• Visit an official website of InsuranceDekho and click on ‘Health’.

• Enter your personal details such as name, age, gender, city, mobile number, no. of members to be covered, and much more. Then click on ‘View Instant Quote’.

• You will able to see the most suitable health plans with their premiums displayed on the screen.

• Among a variety of options, you can select the most suitable plan as per the premium and coverage benefits that are offered by different companies.

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What Are The Factors That Affects Health Insurance Premium?

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The amount which is paid towards getting health insurance coverage is called the health insurance premium. The premium of a particular health policy for an individual is determined by a number of variables. They are described below:

• Age - Companies that provide medical insurance generally adhere to the rule that older the customer, the higher the premiums. This is due to the fact that as people age, their susceptibility to illness increases, increasing the likelihood that they would file a health policy claim. As a result, premiums increase with age and vice versa.

• Pre-medical History/Past Medical History - In case you have a history of any kind of medical condition, then the health insurance company will charge you higher because of the fact that you have a higher chance of getting hospitalised. But you will be charged a comparatively lesser premium if you do not have any past medical problems. However, it is always a better idea to reveal your existing medical conditions to the insurer right at the time of buying a health insurance policy.

• Type of Health Insurance: The type of health insurance plan you are buying also largely affects the premium. For instance, the premium of family health insurance plans is higher as compared to individual health insurance plan due to the fact that family health insurance plan provides coverage for the entire family under one single plan.

• Lifestyle Habits - Lifestyle habits such as excessive smoking or drinking deteriorate your health and make you more prone to illnesses. If you lead this lifestyle, your health may be at risk, increasing your likelihood of filing a claim. You will pay a greater premium for health plan as a result compared to someone who does not smoke or drink frequently.

• Policy Term - Policy term is another crucial factor that decides the premium for a health insurance policy. You can choose from different policy terms such as 1 year, 2 years, or 3 years, according to its terms and conditions. The higher the policy term you opt for, the higher premium you will be required to pay, due to the higher coverage offered.

• Add-On Covers - For comprehensive coverage, you can add add-on covers to your health insurance policy. You will need to pay an additional premium for this when you buy your insurance. The greater the number of add-on covers you buy, the higher premium you will be required to pay for it. However, it is important to note that on including add-ons, you will be entitled to get greater health insurance coverage.

• Co-Payment - Premiums for medical insurance plans that come with a co-payment clause are generally low, due to the cost-sharing involved. Therefore, if you choose a health insurance policy with a co-payment option, then you will be required to pay a lesser premium and vice versa.

• Body Mass Index - You run a higher chance of developing health problems if your body mass index is higher than average. Your premium will be expensive as a result. However, if it is normal, you will be liable to pay a lower premium.

• Occupation: Individuals who are involved in high-risk professions such as mining are liable to pay higher health insurance premiums. This is simply because such individuals pose greater health risks.

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Tips to Reduce Health Insurance Premiums

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Worried about hefty health insurance premiums? Don’t worry, here are some of the useful ways in which you can save on health insurance premiums:

• Buy Your Health Insurance Early: Premiums for health insurance are often based on age and health status. When you buy health insurance at a younger age, you are generally healthier, and insurance companies consider you to be at lower risk for developing health issues. As a result, your premiums are likely to be lower compared to someone who buys insurance at an older age when health risks tend to increase. This is evident from a case where an individual who is 30 years of age is likely to pay higher premiums as compared to one who is 50 years old.

• Choose Adequate Coverage: It is very important that you choose the right kind of coverage with your health insurance plan. For instance, if you are a young individual, then it makes sense to buy an individual health insurance plan. However, if you have a family and dependant parents, then it is best to buy a family health insurance plan as compared to any other plans.

• Compare the Health Insurance Plans: Before buying any health insurance plan, you must first compare it with the different plans available so that you do not end up buying an expensive health insurance plan. On comparing the different health insurance plans available, you will not just be able to buy a plan that suits your budget but also get the right plan for yourself and your family.

• Buy Top-up Plans: You might think that buying a top-up plan will be a costly affair. However, this is not the case, as with top-up health insurance plans, you will be able to boost your health insurance coverage. So, buy top-up plans and be prepared for medical emergencies.

• Choose Only Relevant Add-ons: Health insurance comes with a number of add-ons such as maternity rider, hospital cash rider, critical illness rider, and so many more. However, on adding these add-ons to your health insurance plan, the health insurance premium is likely to go up. So, it is very important that you wisely choose the relevant add-ons.

• Lead a Healthy Lifestyle: There is no surprise that health insurance premiums are higher for those who lead an unhealthy lifestyle. This means that individuals who often drink and smoke or lead an unhealthy lifestyle will ultimately end up paying extra health insurance premiums. So, it is better to lead a healthy lifestyle and save on health insurance premiums.

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How To File A Health Insurance Claim?

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Claim under a health insurance policy can be made in two ways - in a cashless manner and in a reimbursement manner. A cashless claim is when you receive treatment at a network hospital of the insurance provider who is servicing your policy. If the claim request is accepted, the insurance company directly settles the bills at the hospital. Whereas in reimbursement claims, you are required to pay for the hospital bill from your own pocket first, and make a claim request with the insurance company later. The insurance company will process your claim and reimburse you for the same after accepting the claim. You can make a health insurance claim by following the simple steps given below:

• Step 1: Visit the network hospital or the hospital of your choice and inform the insurance company about the hospitalisation.

• Step 2: Fill the pre-authorization form at the hospital’s TPA (third-party administrator) desk.

• Step 3: You will receive an approval letter by the claim management team.

• Step 4: Respond to the query raised by the claim management team, if any.

• Step 5: Avail the required medical treatment.

• Step 6: The insurance company will directly settle the bills at the network hospital as per the terms and conditions mentioned in your policy.

 

Documents Required For Health Insurance Claim Reimbursement

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The documentation needed in the case of a reimbursement claim are as follows:

• Valid identity proof.
• Duly signed and completed original claim form.
• Doctor’s prescription recommending hospitalisation.
• Original pharmacy bills.
• Original prescription for medicines, consultation, and diagnostic tests.
• Indoor case papers.
• Ambulance receipt.
• First Information Report (FIR), if applicable.
• Policy details with the insured person(s) name, policy number, illness, and address.
• Any other document if required by the insurer.

Listed below are additional documents required in case of a cashless medical insurance claim:

• Pre-authorization form.
• Valid identity proof along with a photograph.
• Documents like voter ID card, driving license, PAN card, and Aadhar card.

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Some Myths About Health Insurance

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Due to lack of knowledge and understanding, people in India have a lot of misconceptions when it comes to health plans. It is important to debunk these myths in order to make the best purchasing choices. Here are some popular misconceptions and the truth about health policies:

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Myth 1: Young And Healthy People Do Not Require Health Coverage

Reality: The most effective time to buy a health is a young age. This is because you are young and are less vulnerable to critical illnesses. Hence, the chances of getting hospitalized are low and you will be able to buy a health coverage at an affordable premium. Also, you can serve waiting period of your health plan at young age and get a quality treatment at older age without any obstacles.

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Myth 2: Only Hospitalization Charges Are Covered

Reality: It is true that health insurance plans cover you for hospitalisation expenses only when the hospitalisation of at least 24 hours takes place. But it is not true that the plans only cover you for these expenses. In most cases, they also cover you for daycare procedures such as sinusitis, radiotherapy, chemotherapy, etc, which do not require hospitalisation of at least 24 hours. Other expenses covered are OPD expenses, road ambulance expenses, second medical opinion, medical check-up, etc.

 

Myth 3: People who smoke cannot be covered under any health insurance policy

Reality: You can still buy a health insurance plan even if you are a smoker. But medical insurance companies are concerned about pre-existing conditions, which may even lead to the cancellation of your health insurance application form. So, if there is any pre-existing condition due to smoking, then you must disclose the same to your insurer. It will not deny you the policy but may charge you a higher premium because as a smoker, you will be more prone to illnesses.

 

Myth 4: Health insurance plans are bought to save taxes

Health insurance plans do not only help you save taxes as per the prevalent tax laws but most importantly, cover you for healthcare expenses, which may help you save even more in the long term.

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Myth 5: It is not safe to buy health insurance plans online

Purchasing health plans online through reputable companies such as Aroon Fintech is absolutely safe and easy. All you have to do is fill out a quote, compare the insurance plans offered on the screen, shortlist the one you want to buy for yourself and your family, and pay the premium online through a secure payment method. You can choose from a variety of premium payment methods such as credit cards, debit cards, and e-wallets.