Mediclaim policy needs are different for different people. The core of any insurance plan, as we all know, is a protection of financial loss. Offering protection and alleviating your risk is that the simple motive of an insurance plan. Making that small investment in any health insurance plan, will enable you to be tension-free and offer security in advance. Especially when we are facing the pandemic and the rising cost of treatments makes it even more necessary to buy a health insurance plan. As per IRDA regulation, currently all the treatment cost incurred for Covid 19 are covered under all health insurance policies.
Though we are faced with the pandemic, we all know, insurance may be a critical part of any person’s financial emergency toolkit. Being an Insurance advisor, it is our duty to educate customer’s to importance of health Insurance Policy and what features and benefits customer should opt.
The features breakup has been explained below.
Second Opinion
Many insurers allow this facility at no cost and as an inbuilt feature from their network of medical practitioners mainly when the insured is diagnosed with a specified critical illness.
Global Cover
It covers for medical expenses of the insured person incurred outside India, up to the sum insured, provided that the diagnosis was made in India and the insured travels abroad for treatment. The medical expenses payable shall be limited to in-patient and day-care hospitalization only on reimbursement basis. Cashless facility may be arranged on case-to-case basis. The payment of any claim under this benefit are in Indian Rupees. Insurer requires the subsequent additional documents supporting the claim under this benefit:
- a) Proof of diagnosis in India
- b) Insured’s Passport and Visa
Free Health Check-up
Each insurer has this feature of providing annual health check-up or once in each block of some claim-free years. The eligible amount and the list of tests depends as per the sum insured opted for. One can avail the same as cashless by scheduling an appointment or visiting a Centre of your choice and claim as reimbursement
Restore Benefit
When sum-insured is insufficient because of claim, restoration benefit will be utilised if opted for. Multiple restoration is offered during a policy year for related or unrelated illnesses additionally to the sum insured opted for, depending upon the insurer.
AYUSH Benefit
AYUSH treatment refers to the medical and /or hospitalisation treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems. These treatments are covered only if taken any institute recognised by government and/or accredited by quality council of India/ National Accreditation Board on Health or govt. hospital. Facilities and services availed for pleasure or rejuvenation or as preventive aid, like beauty treatments, Panchakarma, purification, detoxification and rejuvenation, etc. are part of the exclusions.
Home Hospitalization or Domiciliary Hospitalization
Domiciliary hospitalization means medical treatment for an illness/ disease/injury which within the conventional course would require care and treatment at a hospital but is taken while confined domiciliary under any of the subsequent circumstances:
- a) The state of the patient is specified he/she isn’t in a condition to be moved to a hospital for treatment, or
b) The patient had to require the treatment domiciliary within the circumstances of non-availability of a room in a hospital.
Organ Donor
protect medical and surgical expenses of the donor for harvesting the organ where an insured is that the recipient provided that:
- a) The organ donor is any individual whose organ has been made available in compliance with the rules & requirements of The Transplantation of Human Organs (Amendment) Bill, 2011 and
- b) The organ which is being donated by donor is to be used by the insured, and
c) The insurer has accepted an inpatient hospitalization claim for the insured member under in patient hospitalization treatment.
Air Ambulance
An air ambulance is often helpful just in case of medical emergencies. It helps when one is injured during a visit and requires transport facility, in case one requires hospitalisation immediately and it’s impossible to travel road, etc.
Modern Treatments and Dental Treatments
Many insurers have set defined ailments as modern treatments like – Oral-Chemotherapy, Robotics surgery, Bariatric surgeries, stem cell therapy, etc. and the list is defined separately with the defined sum insured for every treatment.
Dental treatment until recently was always covered in case of accident only and now after specified waiting period dental treatments like root canal, cleaning and polishing, etc. could be covered with defined upper limit too.
Pre & Post Hospitalization
Medical expenditures incurred before & after the hospitalization provided that – Such medical costs were incurred for the same illness or the injury for which earlier and subsequent hospitalisation was needed. Also, the number of days differs from insurer to insurer too i.e. for pre-hospitalisation days vary from 30 days to 90 days & 60 to 180 days for post hospitalisation requirements.
Senior Citizen Plans
There are special plans specifically designed for senior citizens and while buying them, the following points are to be considered – waiting period for pre-existing disease, Co-payment, entry age, pre-policy medicals, etc.
No Claim Bonus
In the event of no claim in the policy year, insurer adds a fixed percentage depending upon the product, say from 10% rise each claim-free year subject to maximum 100% of the sum insured. Some insurers offer cumulative bonus not in excess of 250% of the sum insured under the current policy. Disease, Co-payment, entry age, pre-policy medicals, etc.
Day Care Procedures
Generally, an insurer covers listed Day Care treatment due to disease/illness/Injury during the policy period taken at a hospital or a Day Care Centre. The list of treatment varies from insurer to insurer. The scope of the policy cover does not include the treatment normally taken on an out-patient basis.
Pre-Existing Diseases
Pre-Existing disease means any condition, ailment or injury or related condition(s) that there have been signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment was received within specified months before the primary policy issued by the insurer and renewed continuously thereafter
Waiting Period
Any benefits associated with pre-existing condition, ailment or injury until the defined waiting period since inception of policy, provided the pre-existing condition is disclosed within the proposal form. A claim will not be paid for specified diseases like Cataract, Stones in the Urinary and Biliary systems, all types of Sinuses, Joint replacement surgery, Bariatric surgery, etc. until 24 to 36 months of waiting period depending upon the insurer.
Maternity Expenses
Most of the insurers do cover maternity benefits with specified waiting period starting from 9 months to 72 months, the maternity cover depends upon the sum insured and covers normal delivery, C section, lawful termination of pregnancy and infertility treatment too.
.
New- born Baby Cover
It would cover medical expenses incurred towards treatment as inpatient for delivery. Coverage is considered under the maternity cover up to 90 days after birth and within limit of sum insured without paying any additional premium. Mandatory vaccinations of the new -born baby up to 90 days, as recommended by the Indian Paediatric Association will be covered under the maternity expenses. Many insurers offer reasonable and customary charges for vaccination expenses for the new -born baby as per National Immunization Scheme (India), till the baby completes 1-year (12 months) up to the limits specified in the policy schedule.
Room Rent Capping
Every insurer features a thumb rule for the room rent to be charged for an admissible claim. Room rent may be a sub-limit set by insurers mainly under basic sum insured of a private insurer and mostly all govt. sector insurers. It is generally capped at 1% of sum insured for a normal claim and 2% of the sum insured for the ICU claim. The overall billing of the hospitalisation expenses happens based on the room category opted for at the time of claim. All the other charges like nursing, medication, doctor charges, Anaesthetic doctor visit, any other expenses towards hospitalisation forms part of the room rent package selected. So, while applying for claim one must keep this fact in mind.
However, select insurers have began to offer products where there’s no room rent capping surely levels of sum assured, thereby allowing the policy holder to be ready to claim the entire room rent amount, even if it crosses the 1-2% of sum assured limits. This can be very useful, due to the rising costs of medical treatment.
