17 Things to Consider While Buying Health Insurance

What Things to Consider While Buying Health Insurance in India?

It is essential to select a health insurance plan that resonates with the healthcare needs of you and your family. Some of the crucial things to consider before buying medical insurance are as follows:

1. Sum Insured

   When purchasing a mediclaim policy, you must check the sum insured, which is the maximum amount your health insurance company will pay for medical expenses during the policy term. It is crucial to assess your needs and choose a sum insured that aligns with your potential medical costs and lifestyle. For instance, if you live in a metropolitan city where healthcare costs are higher, opting for a higher sum insured is advisable.

2. Waiting Period Clause

   While purchasing a health insurance plan for yourself or your family, you must always check the waiting period. During this period, the insurer does not accept any non-accidental claims, especially concerning specific illnesses. Moreover, pre-existing diseases (PED), like blood pressure, diabetes, thyroid, etc., are covered after the waiting period is over.

   While the initial waiting period is 30 days, the waiting period for specific illnesses and PEDs can range from 12 months to 36 months, as per the insurer and the plan you choose. Moreover, several plans today offer pre-existing disease (PED) cover from day 1 of the policy. Therefore, it is in your best interest to compare and choose a medical insurance plan with the lowest waiting period.

3. Pre and Post-Hospitalisation Cover

   The cost of hospitalization is not just limited to your stay at the hospital. You can incur medical expenses before and after getting hospitalized, which can increase your medical bills. Therefore, a critical point to check before purchasing a mediclaim policy is that your mediclaim policy covers pre and post-hospitalisation expenses.

   Pre-hospitalisation charges, include consultation fees and diagnostic tests, done by the hospital for up to 30, 60 or 90 days before admission. On the other hand, post-hospitalisation costs, like follow-up doctor visits, medical tests, medicines, etc., are incurred for up to 60, 90 or 180 days after you have been discharged from the hospital. However, the exact coverage for pre & post-hospitalization expenses may vary from plan to plan.

4. Restoration Benefit

   Restoration benefit is a useful feature where the insurance company restores your entire sum insured if it gets used up during a claim. For instance, if your parents health insurance policy has a coverage of ₹5 lakh and you use it all for one treatment, the insurer will refill the amount, allowing you to claim again for other medical needs before policy renewal. This is especially beneficial for families or elderly people prone to multiple health issues or accidents in a year.

5. Co-payment Clause

   Before investing in a mediclaim policy, you must check for the co-payment clause. As per this clause, the policyholder must pay a fixed percentage of the hospital bill during claim settlement. Although health policies with the co-payment clause are more affordable, they increase your out-of-pocket expenses since you pay a part of the bill yourself.

   For example, suppose Rahul has a medical insurance policy with a co-payment of 10%. A few months later, he gets hospitalized, and his hospital bill comes out to be ₹5 lakh. In this case, he would need to pay ₹50,000 out of his own pocket, and the remaining ₹4.5 lakh will be paid by his insurer.

   Moreover, many insurers make co-payments mandatory, especially under senior citizen health insurance plans, while others make it optional. So, make sure you check the co-payment clause carefully before buying a policy and prefer plans with no co-payments.

6. Day Care Procedures

   You should check the number of day care treatments covered under your health plan before buying. These treatments/procedures require hospitalization for less than 24 hours. Some of the most common day care procedures are radiotherapy for cancer, cataract surgery, dialysis, etc. Depending on your current health conditions, you should go for a mediclaim policy that covers maximum or all day care treatments.

7. Specific Treatments & Diseases

   Another important consideration while buying a mediclaim policy is coverage for specific treatments and diseases. It is especially important if you have pre-existing conditions or anticipate the need for specialized treatments. Most health insurance companies in India impose waiting periods of up to 3 years or a limit on the coverage for certain procedures like joint replacements or cataract surgeries. So, it is important to understand the coverage and terms and conditions for such treatments before purchasing a plan.

8. Room Rent Capping

   Room rent in health insurance pays for the room rent charges during hospitalization, including ICU and single rooms. Many insurance providers may set an upper limit on the room rent or fix a hospital room category in your health policy. This may change as per the type of room selected. Hence, it is always advisable that you opt for a medical insurance plan with no room rent capping for a better experience.

9. Sub-limits

   You must always check for any sub-limits within your health policy before buying. Sub-limits are capping or maximum limit on expenses, like room rent, ICU charges, specific treatments, etc. For example, your policy may cover only 1% of the sum insured for in-patient hospitalization, which could lead to out-of-pocket expenses if your costs exceed the limit. So, it is important to look for plans with minimal or no sub-limits.

10. No Claim Bonus/ Cumulative Bonus

    Check for the No Claim Bonus or cumulative bonus in your mediclaim policy before purchasing. A No Claim Bonus (NCB) is a discount on renewal premium that your insurer offers for every claim-free year. On the other hand, a cumulative bonus increases your coverage amount for every claim-free year without increasing your premium. The higher the percentage of NCB/cumulative bonus, the more you can benefit. So, opt for a policy with a higher percentage for NCB or cumulative bonus.

    For example, suppose you have a policy of ₹6 lakh, and no claims were filed for two years. Since your health insurance company provides 10% No Claim Bonus for every claim-free year, you get a 20% NCB at the end of 2 policy years. The NCB will keep increasing for subsequent claim-free years until the NCB limit is reached.

11. Preventive Health Check-ups

    Many insurers offer preventive health check-ups as part of policy benefits, which may be available annually or after every few claim-free years. These check-ups help in the early detection of illnesses, ensuring better health management at no extra cost. Hence, you must try to look for policies that offer annual health check-ups so that you can stay proactive about your well-being.

12. Exclusions

    Exclusions are the medical expenses or conditions not covered by the medical insurance policy. Some of the common health insurance exclusions include cosmetic procedures, injuries due to self-harm, substance abuse, and sexually transmitted diseases. Knowing what is not covered under the mediclaim policy will help you avoid claim rejections later. Thus, you must go through the exclusions before buying a policy.

13. Riders/Add-on Covers

    If your medical insurance policy does not provide adequate coverage, you can enhance it by buying add-on covers or riders on the payment of an additional premium. Some of the most common health insurance riders are maternity cover, room rent waiver, global health cover, OPD cover, hospital cash cover, etc. Similarly, some of the most common add-on covers in health insurance are home care treatment, inflation shield, personal accident cover, consumables cover, etc.

14. Modern Treatment Cover

    Modern treatments, like stem cell therapy, immunotherapy, deep brain stimulation, robotic surgeries, etc., can be expensive. Therefore, when purchasing a medical plan, it is essential to check if it covers such new-age treatments. You can also buy them as an add-on cover to avoid out-of-pocket expenses if they are not included in your base policy.

15. Alternative Treatments

    For those who prefer or rely on alternative treatments like Ayurveda, Yoga, Unani, Siddha, or Homeopathy (AYUSH), it is worth checking if the policy covers such treatments. Most insurers offer plans with AYUSH cover. However, the extent and conditions of the coverage may vary depending on the plan.

16. Claim Settlement Turn Around Time (TAT)

    While choosing a health insurance plan, you must check the turnaround time of the insurer for claim settlement. You must prefer an insurance company that has an easy claim settlement process and approves all cashless claims within 1-3 hours. In case of reimbursement claims, go for an insurer that settles claims within 7 working days.

17. Reputation of the Insurer

    Last but not least, check the reputation of the insurance company before finalizing your health policy. You can do so by researching the insurer's Claim Settlement Ratio (CSR), online customer reviews, and service quality. A company with a high CSR of above 90% and positive reviews ensures a hassle-free experience during medical emergencies.