Decide The Sum Insured
The most important factor to consider while buying health insurance is the sum insured. It is the maximum amount the insurer will pay for the medical expenses incurred for any type of hospitalisation.
Since medical inflation is on the rise, adequate coverage is crucial to deal with exorbitant healthcare costs. Make sure you choose a sufficient sum insured that can comfortably meet your medical needs.
Secondly, as you get older, upgrading your health insurance coverage may prove to be challenging due to age and health factors.
Thus, it is important to purchase a health insurance policy that is able to keep up with the increasing medical inflation and provide you with the coverage you need in your later years.
Having comprehensive coverage will ensure that a majority of your medical expenses will be covered by your health insurance. Comprehensive coverage includes coverage for doctor visits, pre and post-hospitalisation costs, daycare treatment costs, ambulance fees, check-ups, etc. You can be sure that you will have access to the care you need with fewer out-of-pocket expenses.
The best health insurance plan should have comprehensive coverage and also reasonable premiums so that you don’t have to use up a huge chunk of your finances for paying premiums. You need to find the right balance between premium cost and coverage. It should be enough to cover your medical costs and shouldn’t hamper your present budget.
Check If Hospitalisation Is Medically Necessary
You can only get health insurance coverage if the hospitalisation/treatment is deemed 'medically necessary'. Hospitalisations and treatments are considered medically necessary if they meet the following 4 conditions:
It is necessary to manage the illness or injury.
It provides safe, adequate, and appropriate medical care in terms of scope, duration, and intensity.
A medical practitioner unrelated to you recommended it.
The treatment complies with professional standards widely accepted in international medical practice.
A claim may be rejected by your insurer if the above conditions are not met.
Check The Room Rent Limit
A room rent limit is the limit up to which your health insurance will cover per-day hospital room charges. Room rent limits are included in most health insurance plans with a sum insured up to Rs. 5 lakhs.
If you choose a room that has a room rent of more than what you’re eligible for under your health insurance plan, the insurer won’t only deduct the difference in room charges but will also proportionately deduct all associated medical expenses.
So, check whether your policy has a room rent limit and try to buy a policy that does not impose such financial restrictions. If your policy has such a limit, you should plan to port to a policy without any limits.
Check The Specific Disease Waiting Period
A waiting period is a duration during which certain illnesses or treatments will not be covered. It applies even if you don't have these diseases at the time of buying the policy. Some insurers may apply a 2-4 year waiting period for treatments for specific diseases like hernia, slipped discs, sinusitis, knee replacement surgery, etc.
Your insurer will not pay a claim for such diseases/treatments if the waiting period specified in your health insurance policy has not been completed. And, upgrades to your health plan will not cover these specific diseases/treatments during the waiting period.
Check For Financial Limits On Specific Treatments/Procedures
Some insurers may put a limit on certain diseases or treatments. With such limits, you may be forced to pay a significant amount even if you have adequate coverage.
For instance, Monica buys a health insurance plan with a sum insured of Rs. 5 Lakhs. In the policy, the limit for hernia surgery is Rs. 50,000. Say she undergoes hernia surgery costing Rs. 1 lakh. In this case, the insurer will only pay Rs. 50,000 and the remaining Rs. 50,000 is her responsibility.
To ensure you are not left with an unexpected expense, you should choose a health insurance policy that does not come with these restrictions.
Keep An Eye On Copayment Clauses
If you have a copayment clause in your health insurance policy, it can affect your claim. Health plans with copay clauses require you to pay a portion of the claim. The insurance company pays the rest. It is best to buy a policy without a copayment clause or with the lowest copay to avoid major expenses from your end.
Assess The Treatment Costs Of Various Hospitals
Hospitals do not have any rules in place when it comes to billing in India. They can charge different rates for the same treatment. And it may get exorbitant.
An insurer primarily looks at the fee charged by similar-grade hospitals in a given area for a specific treatment. Consequently, insurers are able to ensure that they are not overpaying for services that can be acquired at more reasonable prices. They use reasonable and customary charges as a benchmark for determining what is considered a fair price for treatment. So, if you go to a hospital that charges more than what other hospitals in the same area charge, your insurer will only reimburse you for charges that are reasonable and customary.
Non-Medical Expenses Coverage
Health insurance does not provide coverage for non-medical expenses or the cost of consumables such as gloves, nebulization kits, oxygen masks, etc. So, these costs can add up quickly and can be a financial burden in the event of a hospitalisation. So, opt for consumables cover with your health insurance to cover such non-medical expenses.
Fill In The Proposal Form Accurately
The insurer agrees to assume the risk of lifelong hospitalisation or treatment expenses when it offers health insurance policies. Your proposal form serves as the basis for issuing you the policy. Therefore, it is important to ensure that all information you provide is accurate.
If there are any incorrect details or concealment, it can lead to unnecessary complications if the insurer discovers them later. They may reject your claim and even cancel your policy.
So, you should be honest and accurate on the proposal form and provide the insurer with details of any major injuries, illnesses, and surgeries you have had in the past.
Keep Track Of The Policy Conditions
Insurance companies are permitted to change policy benefits, conditions, and costs with the approval of the IRDAI. It is also possible for them to terminate your health insurance plan and migrate you to a different plan with different benefits.
Any changes to the policy terms must be notified to you three months prior to the new terms taking effect. To ensure you stay informed of any changes, it is essential to provide your correct contact information to the insurer and make sure it is updated.
Providing Correct Details To The Doctor
As part of the hospitalisation process, the doctor will ask you about your past medical history, medications, allergies, etc. It is important that all these details are provided to the doctor carefully and accurately. During the course of treatment, doctors compile a case paper that contains details regarding the patient's past medical history, the year of diagnosis, medication, allergies, etc. These case papers will then be shared with the insurance company by the hospital. Hence, it is important to ensure that the case paper contains up-to-date and accurate information.
Maintain Proper Documentation
In order to file a claim for health insurance, you will need to submit various documents like doctors’ prescriptions, diagnostic reports, proof of payment, invoices, etc. If any document is missing, the insurer will deduct that expense before paying the claim.
So, you should maintain a single folder for all your bills, receipts, and other documents. Furthermore, keeping a record of all your documents will save you time and effort when filing a claim. You should pre-number all invoices and receipts you receive from the hospital/doctor. This will make it easier to find the documents you need, so you can focus on the filing process and not waste time searching for them.
Have A Look At The Insurers’ Claim Settlement Ratios (CSR)
CSR refers to the percentage of claims settled against the total number of claims received by an insurance company in a financial year. It helps you gauge the insurer's worth. A company with a high CSR is more likely to settle claims, increasing the likelihood of your claim being approved.
Check The Insurer’s Solvency Ratio
The solvency ratio represents an insurance company's ability to meet long-term financial obligations and settle claims. It reflects the financial status of insurance companies. In accordance with IRDAI regulations, all insurance companies are required to possess a solvency ratio of 150%. A higher solvency ratio signals that a health insurance company is financially stable and has a higher proportion of assets. This means that even if there is a large claim, the company has sufficient financial resources to pay them off.
Verify The Insurer’s IRDAI Approval
The Indian Insurance Regulatory and Development Authority (IRDAI) regulates and develops the country's insurance industry. Insurance companies registered with IRDAI must comply with all of its rules and regulations and be transparent in their operations. In other words, you should always choose an IRDAI-approved company if you want to buy health insurance for yourself or your family - to ensure your hard-earned money doesn't go down the drain.