Health Insurance : Definition, Policies, Coverage, Exclusions, Best Plans, Companies, Claims, Premiums, Benefits | Free Quote Online

Table of Contents

What is Health Insurance?

A Health Insurance is a contract between the Insured and the Insurance Company wherein the Insurance Company reimburses the Insured Person for any hospitalisation expenses upto the Sum Insured incurred during the Policy Period. The Health Insurance Policy also provides coverage for Pre and Post-Hospitalisation Expenses. In return, the Policyholder pays a Premium to the Insurance Company. A Health Insurance Policy provides protection to the Insured against any major medical expenses.

Definition of Health Insurance

What Does a Health Insurance Policy Cover?

Hospitalisation Expenses

Health Insurance Policies cover Hospitalisation Expenses incurred for treatment of illness or injuries, including coverage for expenses such as Room Rent, ICU Charges, Nursing Fees, Doctor’s Fees, Cost of Medicines etc. The only requirement to avail coverage for Hospitalisation expenses under a Health Insurance Policy is that the Policyholder should be admitted to a hospital for more than 24 hours to avail treatment.

Pre and Post-Hospitaliwsation Expenses

A Health Insurance Policy also provides coverage for Pre and Post-Hospitalization expenses for upto 30 days before the date of admission and for upto 60 days after date of discharge. Pre-Hospitalisation expenses cover medical costs incurred before a hospital admission, such as diagnostic tests, consultations, and medications while Post-Hospitalisation expenses, include follow-up consultations, medications, and diagnostic tests required after discharge. Pre and Post-Hospitalisation Expenses constitute a significant amount and coverage for the same is an important benefit provided by the Health Insurance Policy.

Coverage for Daycare Procedures

Daycare Procedures are medical treatments or surgeries that do not require a 24-hour hospital stay due to technological advancement. Health Insurance Policies cover Daycare Procedures such as Cataract Surgery, Chemotherapy, Dialysis, and Minor Surgical Interventions. Coverage for Daycare Procedures ensures that Policyholders can receive necessary treatment without the extended hospital stay, thereby reducing the cost and inconvenience associated with prolonged hospitalization.

Maternity Benefits

Maternity Expenses Coverage are an important benefit provided under many Health Insurance Policies which provide financial support for expenses related to Pregnancy and Childbirth. Maternity Benefits Coverage under a Health Insurance Policy typically cover Prenatal and Postnatal Care, Delivery Expenses, and Newborn Baby Cover. Policies include coverage for both, Normal and Cesarean Deliveries. Maternity Benefits Coverage under a Health Insurance Policy usually has a waiting period, ranging from 9 to 48 months and also a Sub-Limit which is usually around Rs50,000 to Rs1 lakh.

OPD Coverage

Outpatient Department (OPD) Coverage is an important feature in Health Insurance Policies, covering medical expenses incurred without hospitalization. This includes consultations with Specialists, Diagnostic Tests, Pharmacy Bills, and Minor Procedures that do not require an overnight hospital stay. OPD coverage is particularly beneficial for individuals who frequently require medical consultations or treatments.

What are the Add-On Covers in a Health Insurance Policy?

Maternity and New-Born Baby Cover

Some Health Insurance Policies provide coverage for Delivery Expenses as well as Coverage for New-Born Baby as an Add-On Cover on payment of additional Premium. Families who are considering having a Child can consider opting for this cover as the Policy would provide coverage for the same. The Insured should make sure to read the Waiting Period and Sub-Limits for Maternity Coverage under the Policy.

Room Rent Capping Waiver

Health Insurance Policies have Room Rent Limits and Policyholders whose Room Rent exceeds the limit under the Policy must bear the additional expenses themselves. Moreover, all the Health Insurance Policies also have a Proportionate Deduction Clause which means that in case the Room Rent expenses exceed the Limit as specified in the Policy, then all the other expenses will also be deducted on a pro-rata basis as the room rent expenses. This leads to Policyholders having to bear substantial expenses out of their own pocket. To protect oneself from such deduction, the Insured should opt for a Waiver of Room Rent Limit Add-On Cover.

Critical Illness

Some Health Insurance Policies offer a Critical Illness Rider which ays a lumpsum amount to the Insured on the diagnosis of one of the Covered Critical Illness like cancer, heart attacks, kidney failure, paralysis etc subject to the terms and conditions of the Policy. This lumpsum amount can be utilised for treatment of the disease, lifestyle changes, or even a planned treatment outside India etc. Critcal Illness Rider is an important cover to protect oneself from the risk of Critical Illnesses.

International Coverage

Some Health Insurance Policies offer cover for treatments availed outside India as well. Some people prefer to avail treatment for serious ailments like cancer outside India. In such cases, people must purchase a Health Insurance Policy which provides coverage for international treatment.

OPD Coverage

Most Health Insurance Policies do not provide cover for Outpatient Treatment. Outpatient Treatments are treatments which do not require admission to a hospital and include routine medical expenses like Diagnostic Reports and Doctor Consultations. Such medical expenses are substantial and the Insured should purchase a Health Insurance Policy with OPD Coverage to secure himself from such expenses.

Hospital Cash Coverage

Some Health Insurance Policies offer Hospital Cash Cover as an Add-On Cover which provides a fixed cash allowance to the Policyholder for each day of hospitalisation. This allowance can be used to cover miscellaneous and non-treatment expenses.

What are the Exclusions in a Health Insurance Plan?

Health Insurance Policies come with a range of exclusions—specific conditions, treatments, or circumstances that are not covered by the policy. Understanding these exclusions is crucial for Policyholders to avoid unexpected out-of-pocket expenses. Here are some common exclusions in Health Insurance Plans:

  1. Pre-Existing Conditions: Most Health Insurance Policies do not cover Pre-Existing Conditions immediately. There is usually a waiting period of 1 to 4 years, before these Pre-Existing Diseases are covered.
  2. Maternity and Newborn Care: Maternity expenses, including prenatal and postnatal care, are usually excluded unless the Policy explicitly includes coverage for maternity benefits. Even with coverage, there is typically a Waiting Period and Sub-Limit.
  3. OPD Treatments: Outpatient Department (OPD) Treatments, which include Consultations, Diagnostic Tests, and Minor Procedures that do not require hospitalization, are generally excluded unless specifically included in the plan.
  4. Self-Inflicted Injuries: Injuries or illnesses resulting from self-harm, suicide attempts, or voluntary exposure to danger are not covered.
  5. Substance Abuse: Medical expenses arising from the use of alcohol, drugs, or other intoxicants are typically excluded.
  6. War-Related Injuries: Injuries or illnesses resulting from war, acts of terrorism, civil war, or nuclear risks are usually excluded.
  7. Sexually Transmitted Diseases (STDs) and HIV/AIDS: Many policies exclude coverage for treatment related to STDs and HIV/AIDS, although some newer plans are beginning to include limited coverage for these conditions.
  8. Cosmetic and Aesthetic Treatments: Procedures such as Plastic Surgery, Botox, and other Cosmetic Treatments are generally not covered unless they are necessary due to an accident or reconstructive surgery.

Major Types of Health Insurance Policies

Individual Health Insurance Policy

An Individual Health Insurance Policy cover the Hospitalisation Expenses of a single person. This Policy provides coverage for Hospitalization Costs, Pre and Post-Hospitalization Expenses, Daycare Procedures, and sometimes includes benefits like Ambulance Charges and Preventive Health Check-Ups. The Sum Insured under an Individual Health Insurance Policy is solely dedicated to the Individual Policyholder, ensuring that the entire amount can be utilized as needed. This type of plan is ideal for young professionals, single individuals, or those who want a dedicated Health Insurance Policy.

Family Floater Health Insurance Policy

A Family Floater Health Insurance Policy provides comprehensive Health Insurance Coverage for an entire family under a single Insurance Policy. The Sum Insured under a Family Floater Health Insurance Policy is shared among all family members, which typically includes the Policyholder, Spouse, Children, and sometimes Parents. One of the key advantages is that the premium for a Family Floater Health Insurance Policy is generally lower than purchasing Individual Health Insurance Policy for each family member. This type of plan is ideal for families seeking affordable Health Insurance Coverage, ensuring that any member can utilize the Policy Benefits as needed.

Senior Citizen Health Insurance Policy

A Senior Citizen Health Insurance Policy is a Health Insurance Plan specifically designed for Senior Citizens aged 60 years and above. The Policy provides coverage for Hospitalisation Expenses, Pre and Post-Hospitalisation Expenses, Daycare Procedures etc. These plans cater to the unique health needs of older adults, often covering Age-Related Diseases, and providing coverage for Pre-Existing Diseases after a waiting period. Given the increased health risks associated with aging, these plans come with higher premiums but provide essential financial protection for medical expenses in the later stages of life.

**Super Top-Up Health Insurance Policy

A Super Top-Up Health Insurance Policy provides additional coverage over and above the existing Health Insurance Policy once a certain Deductible limit is exceeded. Unlike regular Top-Up Health Insurance Plans, which activate only once a single Claim exceeds the Deductible Amount, a Super Top-Up Health Insurance Policy considers the cumulative medical expenses in a policy year. A Super Top-Up Health Insurance Plan is ideal for individuals or families who want to enhance their existing Health Insurance Coverage at reasonable premiums.

Critical Illness Health Insurance Policy

A Critical Illness Health Insurance Policy provides a lumpsum benefit to the Insured upon the diagnosis of specified critical illnesses such as cancer, heart attack, stroke, kidney failure, and major organ transplants. This Lumpsum amount can be used for treatment, recovery, and even non-medical expenses like paying off debts or making lifestyle adjustments. A Critical Health Insurance Policy is essential because critical illnesses often lead to significant medical costs and loss of income due to prolonged treatment and recovery periods. By offering a financial cushion, critical illness plans help policyholders manage the high expenses associated with severe health conditions, ensuring financial stability during challenging times.

Important Terms in Health Insurance

Sum Insured

Sum Insured in a Health Insurance Policy is the total amount that the Policyholder will be covered for medical expenses during a Policy Term. Sum Insured is a critical factor to consider when purchasing a Health Insurance Plan as it determines the amount of coverage that the Insured will receive in case of a Claim. The Policyholder should consider factors such as age, medical history, lifestyle, and the cost of healthcare in his area when choosing a Sum Insured under the Policy.

No Claim Bonus

No Claim Bonus (NCB) in a Health Insurance Policy is defined as an increase or addition in the Sum Insured of the Policy granted by the Insurance Company to the Policyholder without an associated increase in Premium. No Claim Bonus (NCB) is a reward for policyholders who do not make any claims during a policy year and is granted in the form of increased Sum Insured during the subsequent Policy Year. It is given to policyholders to incentivize good health and avoid making unnecessary claims. NCB accumulates over the years, thus enhancing your coverage over the years.

Restoration Benefits

Restoration Benefit, also known as Refill Benefit, is a feature of Health Insurance Policy where the Insurance Company reinstates the Sum Insured under the Policy after the it is exhausted due to a Claim raised under the Policy. Restoration Benefit in Health Insurance ensures that the Policyholder has continuous coverage for other illnesses or injuries even after the initial Sum Insured is exhausted. It is particularly useful for Family Floater Health Insurance Plans, where multiple members are covered under a common Sum Insured. It’s essential to understand the conditions under which Restoration Benefits apply, as some policies may only restore the Sum Insured for unrelated illnesses or accidents.

Waiting Period

Waiting Period in a Health Insurance Policy refers to the duration that the Insured Person needs to wait before the Policy pays claim for that specified purpose. Health Insurance Policies have various types of Waiting Periods such as an Initial Waiting Period (usually 30 days), Specific Disease Waiting Period, and Pre-Existing Disease Waiting Periods. It’s crucial to understand these Waiting Periods to know when the coverage would commence. Choosing a Health Insurance Policy with lower waiting periods provides quicker access to coverage for various medical conditions.

Pre-Existing Diseases

Pre-Existing Disease means any condition, ailment or injury or disease which are diagnosed by a Physician before purchasing the Health Insurance Policy. Most Health Insurance Policies have a waiting period of 1 to 4 years before they provide coverage for Pre-Existing Diseases. The Insured must disclose all Pre-Existing Conditions at the time of buying the Policy to avoid claim rejections.

Room Rent Limit

Room Rent Limit in Health Insurance is a limit on the cost of the hospital room that will be borne by the Insurance Company. Health Insurance Policies often specify limits on Room Rent, either as a fixed amount or a percentage of the sum insured. Choosing a Policy with adequate Room Rent Coverage is important because exceeding the limit can lead to Claim Deductions. Some policies offer single private rooms, while others may cover shared or general ward accommodation. Understanding the room rent limits and opting for coverage that aligns with your comfort and medical needs can prevent unexpected expenses during hospitalisation.

Daycare Procedures

Daycare Procedures are medical treatments or surgeries for which treatment can be availed within 24 hours and that do not require a patient to be hospitalised because of technological advancements. Health Insurance Policies cover a wide range of Daycare Procedures, such as Cataract Surgery, Chemotherapy, Dialysis etc. Coverage for Daycare Procedures is essential as it ensures that policyholders receive necessary treatments without the need for prolonged hospital stays. When purchasing a Health Insurance Policy, the Insured review the list of daycare Procedures covered under the Policy to ensure it includes treatments relevant to your health needs.

Co-Payment

Co-Payment means a cost sharing requirement under a Health Insurance Policy which states that that the Insured will bear a fixed percentage of the admissible claims amount. A Co-Payment does not reduce the Sum Insured. For example, if a Policy has a 10% Co-Payment Clause, it means that the Insured pays 10% of the bill, and the Insurance Company pays 90%. Co-Payment Clause helps the Insurance Companies manage risk and keep Premiums lower. Policyholders must read the Policy Wordings thoroughly for the Co-Payment Percentage under the Policy and consider their ability to pay the Co-Payment amount during a medical emergency. Policies with lower or no Co-Payment are preferable for those seeking to minimise out-of-pocket expenses.

OPD Cover

Outpatient Department (OPD) cover in Health Insurance Policies provides reimbursement for medical expenses incurred for treatment received without getting admitted. OPD treatments include Consultations, Diagnostic Tests, Pharmacy, and Minor Procedures. Some health Insurance Policies provide coverage for OPD expenses and this helps in managing routine healthcare expenses and minor ailments that do not require hospital admission. While OPD Cover in Health Insurance increases Policy Premiums, it offers significant benefits for individuals who frequently need medical consultations and outpatient treatments.

Sub-Limit

A Sub-Limit in a Health Insurance Policy is a pre-determined capping on an Insurance Claim for certain medical expenses and surgeries. So, it is basically a limit up to which the insured will be covered for the specific ailment or room rent. Sub-Limits are usually expressed as a percentage of Sum Insured. For example, a Health Insurance Policy might have a sub-limit of Rs40,000 for Cataract Surgery. This means that the Policy will pay a maximum of Rs40,000 for a Cataract Claim. Sub-Limits help Insurance Companies control costs and manage claims more effectively. However, they can also result in out-of-pocket expenses for Policyholders if the actual costs exceed the sub-limits. It’s essential to carefully review a Policy’s Sub-Limits to avoid unexpected expenses during hospitalisation.

Congenital Disease Coverage

Congenital Diseases are diseases that exist since the time of birth. A Congenital Disorder or a Congenital Disease is a birth defect caused by genetic or environmental factors. There are 2 types of Congenital Diseases: Internal Congenital Diseases and External Congenital Diseases. Congenital Disease cover in a Health Insurance Policy pays for medical expenses related to congenital anomalies. Some Health Insurance Policies offer coverage for these Congenital Conditions, either as part of the standard plan or as an add-on rider. It is important to check the specific Terms and Conditions of the Policy regarding Congenital Disease Coverage to ensure adequate coverage.

Domiciliary Hospitalisation Cover

Domiciliary Hospitalization cover provides coverage for treatments that would normally require hospitalization but are carried out at home due to the patient’s condition or lack of hospital beds. Domiciliary Hospitalisation Cover includes expenses for Medical Treatments, Nursing Care, and medication administered at home. Domiciliary Hospitalisation Cover is useful for patients with mobility issues. However, Insurance Companies may impose conditions such as a minimum number of days for the treatment and exclusions for certain ailments. It is necessary for the Policyholders to understand the terms of Domiciliary Hospitalization Cover which can help ensure that patients receive necessary care without financial strain.

Incurred Claim Ratio

The Incurred Claim Ratio (ICR) is a metric used to assess an Insurance Company’s efficiency and reliability in settling Claims. Incurred Claim Ratio is the ratio of Value of Net Claims Settled by an Insurance Company against the Total Premiums collected by the Insurance Company during a particular year. For Example, if the Incurred Claim Ratio is 80%, it means that the Insurance Company is paying out Rs80 in Claims for every Rs100 it collects in the form of premiums. A higher ICR indicates better Claim Settlement. Conversely, a low ICR might imply Stringent Claim Processing. Policyholders should consider ICR while choosing a Health Insurer to gauge their Claim Settlement Efficiency.

Grace Period

Grace Period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue an Insurance Policy in force without loss of Policy Benefits. Grace Period is the additional time given to Policyholders after the due date to pay their Health Insurance Premiums and continue their Policy Benefits. Grace Period typically ranges from 15 to 30 days, depending on the Insurer and Policy Terms. During the Grace Period, Insurance Coverage is not available for the period for which the Premium is not paid by the Policyholder. If the premium is not paid within the Grace Period, the Policy lapses and coverage ceases.

Free Look Period

Free Look Period is a timeframe during which the Policyholder can review the Policy Terms and Conditions. If dissatisfied, the Policyholder can cancel the Policy and receive a full refund of the Premium Paid. Mostly Health Insurance Policies offer a Free Look Period of upto 15 days. The Free Look Period provides an opportunity for Policyholders to thoroughly assess the Policy’s Suitability and make an informed decision without financial loss.

Deductible

A Deductible is the amount a policyholder must pay out-of-pocket before the Health Insurance Company begins to cover medical expenses. For instance, if a Policy has a deductible of Rs10,000, the Insured must pay the first Rs10,000 of medical expenses out of his own pocket, after which the Insurer will cover the remaining expenses as per Policy Terms. Deductibles help reduce the premium cost but also mean higher initial out-of-pocket expenses for the Policyholder.

Entry Age

Entry age is the minimum age at which a Person can be offered Health Insurance Coverage. Most Health Insurance Policies have a minimum entry age of 18 years for adults and 91 days for Dependent Children

Exclusions

Exclusions in a Health Insurance Policy refer to conditions or circumstances which the Health Insurance Policy does not provide coverage for. For example, Health Insurance Policies do not provide coverage for Medical expenses arising from the use of alcohol, drugs, or other intoxicants. Thus, any Claims arising because of alcohol or drug use is not payable under the Policy.

Family Floater

Family Floater is a type of coverage in a Health Insurance Policy where all the family members are covered under a single Policy and share a common Sum Insured. Any family member covered under a Family Floater Health Insurance Policy can utilise the whole Sum Insured of the Policy should a need arise.

Claim

A Claim is a formal request by the Policyholder requesting for compensation for hospitalisation expenses covered under the Health Insurance Policy.

Network Hospital

Network Hospitals are the hospitals which are empanelled with the Insurance Company and can offer cashless claim settlement to the Policholders.

Portability

Portability in Health Insurance refers to shifting the Health Insurance Plan from one Insurance Company to another without losing continuity benefits like Pre-Existing Disease Coverage, Waiting Period etc.

List of Health Insurance Companies in India

S.No Company Name Incurred Claim Ratio (2022-23) Network Hospitals (2022-23)
1 Acko General Insurance Co. Ltd. 88.46% 14,000+
2 Aditya Birla Health Insurance Co. Ltd. 63.00% 11,000+
3 Bajaj Allianz General Insurance Co. Ltd. 79.93% 18,400+
4 Care Health Insurance Ltd. 56.00% 9,400+
5 Cholamandalam MS General Insurance Co. Ltd. 90.62% 12,000+
6 Future Generali India Insurance Co. Ltd. 81.60% 8,000+
7 Go Digit General Insurance Ltd. 85.64% 16,400+
8 HDFC ERGO General Insurance Co. Ltd. 85.40% 13,000+
9 ICICI Lombard General Insurance Co. Ltd. 83.06% 9,500+
10 IFFCO Tokio General Insurance Co. Ltd. 112.90% 7,000+
11 Kotak Mahindra General Insurance Co. Ltd. 56.82% 9,450+
12 Liberty General Insurance Co. Ltd. 74.33% 6,000+
13 Magma General Insurance Co. Ltd. 74.72% 7,200+
14 ManipalCigna Health Insurance Co. Ltd. 66.00% 8,500+
15 National Insurance Co. Ltd. 102.47% 6,000+
16 Navi General Insurance Co. Ltd. 60.15% 11,000+
17 Niva Bupa Health Insurance Co. Ltd. 55.00% 10,000+
18 Raheja QBE General Insurance Co. Ltd. 139.29% 5,000+
19 Reliance General Insurance Ltd 95.82% 10,000+
20 Royal Sundaram General Insurance Co. Ltd. 85.81% 10,000+
21 SBI General Insurance Co. Ltd. 85.44% 16,000+
22 Star Health and Allied Insurance Co. Ltd. 65.00% 14,000+
23 Tata AIG General Insurance Co. Ltd. 79.74% 10,000+
24 The New India Assurance Co. Ltd. 104.00% 2,055+
25 The Oriental Insurance Co. Ltd. 124.97% 4,000+
26 United India Insurance Co. Ltd. 89.21% 14,000+
27 Universal Sompo General Insurance Co. Ltd. 109.41% 4,000+
28 Zuno General Insurance Co. Ltd. 92.12% 10,000+

Best Health Insurance Plans in India

The list of best Health Insurance Plans along with their features and benefits are listed bellow:

Plan Name Sum Insured No Claim Bonus/Cumulative Bonus Restoration Benefit Waiting Period Other Benefits
HDFC Optima Secure Rs5 lakhs to Rs2 Crores 100% Bonus on Day 1 50% each year for next 2 years Total Bonus of 200% Yes, for partial and total claims Waiting Period for PED - 36 months Waiting Period for Specific Diseases - 24 months Zero Deduction on Non Medical Expenses Pre and Post Hospitalisation Expense Coverage for 60-180 Days respectively Domicialiary Hospitalisation Expenses Covered
ICICI Lombard Health AdvantEdge Apex Plus Rs5 lakhs to Rs3 Crores 20% of Sum Insured upto a maximum of 100% Yes, for partial and total claims Waiting Period for PED - 24 months Waiting Period for Specific Diseases - 24 months Worldwide Coverage available for Sum Insured of Rs25 Lakhs and Above Maternity Coverage available as an Add-On Cover upto 10% of base SI subject to maximum of 10 lakhs Critical Illness Cover available with Sum Insured equal to the Policy Sum Insured subject to a maximum of Rs50 lakhs
Bajaj Allianz Health Guard Platinum Plan Rs5 lakhs to Rs1 Crore 50% of base Sum Insured per annum for first 2 years and later 10% of base Sum Insured per annum for next 5 years Total Bonus of 150% Yes, only if the complete Sum Insured has been exhausted Waiting Period for PED - 36 months Waiting Period for Specific Diseases - 24 months Maternity Coverage available upto Rs25,000-Rs35000 for Normal-Caesarean Delivery after a Waiting Period of 72 months New Born Baby Coverage Recharge Benefit which increases the Sum Insured by 20% upto a maximum of Rs5 Lakhs in case the Claim Amount exceeds the Sum Insured
SBI General Health Edge Policy Rs3 lakhs to Rs25 lakhs Yes, Available as an Add-On Cover 50% of Base Sum Insured up to a maximum of 200% of Base Sum Insured Reduction in Sum Insured is same proportion in case claim is settled Yes, available as an Add-On Cover for partial and total claims. Restore Benefit will be applicable from the fiest claim itself Waiting Period for PED - 24 months Waiting Period for Specific Diseases - 24 months Maternity Coverage available as an add-on cover upto Rs25,000-Rs50,000 for Normal-Caesarean Delivery after a Waiting Period of 48 months New Born Baby Coverage and Assisted Reproduction Coverage available as an add-on cover Global Coverage available for treatment of 16 listed serious illnesses OPD Coverage available as an Add-On Cover
TATA AIG Medicare Premier Rs5 lakhs to Rs3 Crores 50% of base Sum Insured per annum for first 2 years upto a maximum of 100% Reduction in Sum Insured is same proportion in case claim is settled Total Bonus of 100% Yes, only if the complete Sum Insured has been exhausted Restoration benefit is applicable for unrelated illnesses. For Related Illness, the insured person has to be admitted to hospital after 45 days from the date of discharge of the earlier claim. Waiting Period for PED - 36 months Waiting Period for Specific Diseases - 24 months Worldwide Coverage available for Planned Hospitalisation provided that the diagnosis was made in India and the Insured travels abroad for treatment Maternity Coverage available for Rs50,000 for Sum Insured upto Rs50 lakhs and Rs1 lakh for Sum Insured between Rs75 lakhs to Rs3 Crores after a Waiting Period of 4 years OPD Coverage available after a Waiting Period of 2 Years

What is the Entry Age to Purchase a Health Insurance Plan in India?

The entry age to purchase a Health Insurance Plan in India varies depending on the specific plan and the insurance provider. Most Health Insurance Plans have ab Entry age of 18 years to 65 years for adults while the entry age for Dependent Children is between 90 days and 25 years. Senior Citizen Health Insurance Plans have an Entry Age of 60 years plus.

What are the benefits of a Health Insurance Policy?

Hospitalisation Expenses Coverage

One of the primary benefits of Health Insurance is the coverage for Hospitalization Expenses. This includes costs incurred during in-patient hospitalization, where the patient is admitted for more than 24 hours. Health Insurance Policies cover Room Rent, ICU charges, Nursing Fees, and other associated costs under the In-Patient Hospitalisation Coverage.

Pre and Post-Hospitalisation Expenses Coverage

Health Insurance Policies also cover Pre-Hospitalisation Expenses, such as Diagnostic Tests, Doctor Consultations and Post-Hospitalisation Expenses, such as Follow-Up Treatments, Medications, and Rehabilitation Costs. Generally, Pre-Hospitalisation Expenses are covered for up to 30 days before hospitalization, while Post-Hospitalisation Expenses are covered for up to 60 days after discharge. Pre and Post-Hospitalisation Expenses constitute a significant sum and coverage for the same reduces the financial strain on the Insured.

Coverage for Daycare Procedures

Health Insurance Plans also cover Daycare Procedures, which typically require medical treatment or surgeries for less than 24 hours due to technological advancements. Examples include cataract surgery, chemotherapy, and dialysis. Coverage for Daycare Procedures helps manage the costs of short-term medical treatments, ensuring you receive timely care without the financial burden of a full hospital stay.Daycare Procedures are medical treatments or surgeries that do not require a 24-hour hospital stay due to technological advancement. Health Insurance Policies cover Daycare Procedures such as Cataract Surgery, Chemotherapy, Dialysis, and Minor Surgical Interventions. Coverage for Daycare Procedures ensures that Policyholders can receive necessary treatment without the extended hospital stay, thereby reducing the cost and inconvenience associated with prolonged hospitalization.

Coverage for Pre-Existing Diseases

Pre-Existing Diseases are medical conditions that exist before purchasing the Policy. Health Insurance Plans provide coverage for Pre-Existing Diseases after a Waiting Period of 3-4 Years. Coverage for Pre-Existing Diseases is an essential benefit for Policyholders as they are more likely to have medical expenses arising on account of Pre-Existing Diseases.

Tax Benefits of Health Insurance under Section 80D of Income Tax Act 1961

The Premiums paid for Health Insurance Policies are eligible for Tax Deductions under Section 80D of the Income Tax Act, 1961. Policyholders can claim deductions on premiums paid for themselves, their spouses, children, and parents. Section 80D of Income Tax Act, 1961 allows a total deduction of upto Rs25,000 in a financial year for Health Insurance Premiums paid for Self, Spouse and Dependent Children aged below 60 years and up to Rs50,000 in a financial year for Self, Spouse and Dependent Children aged 60 years and above. The Section also allows a total deduction of up to Rs25,000 in a financial year for Health Insurance Premiums Paid for Parents aged below 60 years and up to Rs50,000 in a financial year for Parents aged 60 years and above.

Lifetime Renewal

Health Insurance Policies in India allow Lifetime Renewals as long as the Policyholder pays the premiums on time. Lifetime Renewability is a critical feature of Health Insurance Policies, allowing Policyholders to renew their plans without any age restrictions. This benefit is particularly important for Senior Citizens who face higher health risks and might otherwise lose coverage at an old age.

Why Should You Buy a Health Insurance Policy?

Peace of Mind

A Health Insurance Policy offers peace of mind by ensuring that you are financially protected against unexpected medical emergencies. Medical crises can arise without warning, and the associated costs can be overwhelming. A Health Insurance Policy provides the surety that these expenses will be covered, allowing you to focus solely on recovery.

Afford Quality Treatment

Today, quality medical care is exorbitantly expensive and having comprehensive Health Insurance Coverage is crucial for affording quality medical treatment. Health Insurance Policies offer access to a broad network of hospitals, ensuring that you receive the best possible care without worrying about the costs. This includes Advanced Treatments, Specialist Consultations, and High-Quality Medical Procedures that might otherwise be financially out of reach. A Health Insurance Policy ensures that you do not have to compromise on the quality of healthcare due to financial constraints. This access to superior medical facilities and treatments significantly enhances the quality of medical care that you receive.

Tax Benefits

A Health Insurance Policy offers substantial tax benefits under Section 80D of the Income Tax Act, 1961. Premiums paid for Health Insurance Policies for yourself, your Spouse, Children, and Parents are eligible for tax deductions. Policyholders can claim a total deduction of upto Rs25,000 in a financial year for Health Insurance Premiums paid for Self, Spouse and Dependent Children aged below 60 years and up to Rs50,000 in a financial year for Self, Spouse and Dependent Children aged 60 years and above.
Additionally, Section 80D also allows a deduction for Health Insurance Policy purchased for Dependent Parents up to Rs25,000 in a financial year for Health Insurance Premiums Paid for Parents aged below 60 years and up to Rs50,000 in a financial year for Parents aged 60 years and above.

Beat Rising Medical Expenses

The cost of healthcare is continually increasing, making it difficult to afford quality medical treatment without incurring significant expenses. A Health Insurance Policy helps you manage these rising costs by covering a substantial portion of medical expenses, including hospitalization, surgeries, and medications. Regular Premium Payments ensure that you are protected from the financial impact of unexpectedly high medical bills. Additionally, Health Insurance often includes benefits like annual health check-ups and preventive care, which can help detect and manage health issues early, further reducing long-term medical costs.

Factors to Consider Before Purchasing a Health Insurance Policy

Sum Insured

Sum Insured in a Health Insurance Policy is the maximum amount that the Insurance Company will pay for medical expenses incurred because of hospitalisation. It’s important to choose a Sum Insured that adequately covers potential medical costs, taking medical inflation into account. A higher Sum Insured provides better financial protection but comes with higher Premiums. Assess your health risks, family medical history, and lifestyle to determine an appropriate Sum Insured.

Premium

Premium is the amount that the Policyholder pays to maintain coverage under a Health Insurance Policy. It’s important to balance the premium with the Health Insurance Coverage received. Lower premiums might be attractive but could come with higher out-of-pocket costs during Claims. Policyholders should compare features and benefits of different Health Insurance Plans to find one that offers comprehensive coverage at a reasonable premiums.

Cashless Hospital Network

A robust Cashless Hospital Network allows Policyholders to receive treatment at the network hospitals without paying money out of their own pocket. The Insurance Company settles the bill directly with the Hospital on behalf of the Policyholder. The Insured should choose an Insurance Company with a large network of hospitals, especially those near his residence. This ensures you have access to quality healthcare facilities in emergencies without financial strain.

No Claim Bonus (NCB)

No Claim Bonus in a Health Insurance Policy provides an increase or addition in the Sum Insured of the Policy without an associated increase in Premium. No Claim Bonus (NCB) is a reward for Policyholders for not making any Claims during a Policy Year. Policyholders should choose a Health Insurance Policy with appropriate No Claim Bonus as it translates into increased coverage in the future.

Restoration Benefit

Restoration Benefit in a Health Insurance Policy restores the Coverage Amount under the Policy after the Policy Sum Insured is exhausted due to a Claim raised under the Policy. Restoration Benefit is important for Family Floater Health Insurance Policies as multiple people share a common Sum Insured amongst themselves and the Sum Insured is more likely to get exhausted in such a case. Restoration Benefit comes to the aid in such a situation and reinstates coverage after the Sum Insured is exhausted. Policyholders should choose a Health Insurance Policy which has a Restoration benefit which can be utilised even after Partial Utilisation of Sum Insured and also one which can be used for same/related illnesses.

Pre and Post-Hospitalisation Coverage

Pre and Post-Hospitalisation coverage provides coverage for medical expenses incurred prior to hospitalisation and post discharge as well. Pre and Post-Hospitalisation Expenses constitute a significant percentage of Medical Expenses and Policyholders should choose a Policy which offers Pre and Post-Hospitalisation Coverage of at least 60-90 days respectively.

Waiting Period for Pre-Existing Diseases

Pre-Existing Diseases are medical conditions which are already existing before the Policyholder purchases the Policy. Most Health Insurance Policies have a Waiting Period for Pre-Existing Diseases, ranging from 2 to 4 years. During this period, claims related to Pre-Existing Conditions are not covered by the Policy. The Insured should compare the Waiting Period for Pre-Existing Diseases amongst multiple Health Insurance Plans before finalising the Policy.

Maternity Coverage

Some Health Insurance Policies provide Maternity Coverage which includes expenses related to Childbirth, Prenatal and Postnatal Care. Policies providing Maternity Coverage have significantly higher premiums and also sub-limits for Maternity Expenses that can be claimed under the Policy. The Insured should compare the assess the costs and benefits of availing Maternity Coverage under the Policy. If the Insured is not likely to have children during the Policy Term, he/she should not purchase a Policy with Maternity Coverage and pay higher premiums. The Insured should also compare the Sub-Limits, Waiting Periods and Premiums of a Plan with and without Maternity Coverage to make an informed choice.

Claim Settlement Ratio

Claim Settlement Ratio indicates the percentage of Claims settled by the Insurer against the total Claims received. A higher ratio reflects the Insurer’s reliability in processing and paying out claims. Choose Insurers with a high Claim Settlement Ratio to ensure your Claims are likely to be settled promptly.

Incurred Claim Ratio

Incurred Claim Ratio (ICR) is the ratio of Value of Net Claims Settled by an Insurance Company against the Total Premiums collected by the Insurance Company during a particular year. An Incurred Claims Ratio between 75% and 90% is ideal, indicating the Insurance Company is efficient ins paying claims and not rejecting them unnecessarily.

Lifetime Renewal

Lifetime Renewal of Health Insurance Policy ensures that the Policyholder can renew his Health Insurance Policy without any upper age limit as long as premium is paid on time. This feature is crucial as medical needs increase with age. Policyholder must opt for policies offering Lifetime Renewability to avoid losing coverage at an old age, ensuring long-term financial protection for medical expenses.

What are the Documents required to purchase a Health Insurance Policy?

Policyholders need to provide the following documents to purchase a Health Insurance Policy

  1. Identity Proof: To verify your identity, the Policyholder must provide any of the following documents: Aadhar card, Passport, Voter ID card, Pan Card or Driving License
  2. Address Proof: For address verification the Policyholder must submit any of the following documents: Aadhar card, Passport, Voter ID card, Driving License, Utility bills or rental agreement
  3. Age Proof: The Policyholder must provide either a Birth Certificate, Aadhar or Passport Copy to verify his age.
  4. Medical Reports: The Policyholder must also submit medical reports so that Insurance Companies can assess the health status of the Insured.
  5. Proposal Form: The Policyholder must submit a duly filled and signed proposal form provided by the Insurance Company. This form includes personal details, medical history, and the type of coverage required.
  6. Previous Policy Details: If the Policyholder is switching from another Insurance Company, he needs to provide copies of the Previous Policies of last 3 years.
  7. Bank Details: For premium payments or claim reimbursements, the Policyholder must provide a cancelled cheque copy. The Policyholder can purchase a Health Insurance Policy after providing these documents to the Health Insurance Company.

Factors that Impact Health Insurance Premium

Sum Insured

Sum Insured is an important factor influencing the Premium of a Health Insurance Policy. It represents the maximum amount that the Insurance Company will pay for medical expenses in the event of a claim. Health Insurance Policies with a higher Sum Insured are more expensive than Health Insurance Policies with a lower Sum Insured. When choosing the Sum Insured of a Health Insurance Policy, the Policyholder must balance the need for adequate coverage with what they can afford in terms of Premium Payments. Selecting a Sum Insured that matches the healthcare needs and potential medical expenses is critical.

Coverages

The Coverages included in the Health Insurance Policy directly impacts the Premium. Comprehensive plans that cover a wide array of medical expenses such as Hospitalization, Pre and Post-Hospitalization, Daycare Procedures, and Critical Illnesses will have higher premiums than basic plans. Additional coverages like Maternity Benefits, OPD Coverage, International Coverage etc. also contribute to higher premiums. The Policyholders must assess their healthcare needs and choose coverages that provide the best value for money while ensuring they are protected against significant medical costs.

Type of Health Insurance Plan

The type of Health Insurance Plan also affects the premium. Individual Health Insurance Plans, Family Floater Health Insurance Plans, Critical Illness Plans, and Group Health Insurance Plans all have different premium structures. For instance, Family Floater Health Insurance Plans cover multiple members under a common Sum Insured, generally making them more cost-effective than Individual Plans for each family member. Critical Illness Plans offer Lumpsum Payouts only for specific illnesses and thus have lower premiums as compared to comprehensive Health Insurance Policies.

Age of the Insured

Age is a critical factor in determining Health Insurance Premiums. Younger People typically pay lower Premiums because they are considered less risky and less likely to make Insurance Claims compared to older individuals. As age increases, the likelihood of health issues and claims also rises, leading to higher Premiums. Policyholders should purchase a Health Insurance Policy at a younger age to benefit from Lower Premiums and continuous coverage.

Policy Duration

The duration of the Health Insurance Policy also impacts the premium. Policies with longer durations, such as 2 or 3 years, often come with discounts compared to annual policies. Insurance Companies offer these incentives to encourage long-term commitments. Opting for a multi-year policy can be more economical in the long run, providing protection against Premium increases.

Add-On Covers

Add-On Covers enhance the base Policy by providing additional benefits, but they also increase the Premium. Common add-ons include Critical Illness Cover, Personal Accident Cover, Hospital Daily Cash, and Ambulance Cover. While these add-ons offer extra coverage, each cover raises the overall Premium.

What is the Claims Process in Health Insurance?

The steps to file an Insurance Claim with a Health Insurance Company is listed below:

Intimate Health Insurance Claim to the Insurance Company

You need to intimate the claim to the Insurance Company by either:

  1. Go to the Insurance Company’s Website, Click on Claims and register a claim by providing details like Insured Information, date of hospitalisation, Policy Number etc.
  2. The Insurance Company will provide a Claim Intimation number upon successful registration of the Claim

Cashless Claims Settlement Process in a Health Insurance Policy

Cashless Claims Settlement is a convenient feature offered by Health Insurance Companies, allowing Policyholders to receive treatment at network hospitals without paying upfront for medical expenses. The Policyholder should follow the below mentioned steps in order to avail Cashless Claim Settlement Insurance Company under the Health Insurance Policy

  1. Identify Network Hospital: Ensure that the hospital is part of the Health Insurance Company’s network.
  2. Show Health Card: Present your Health Insurance Card at the Insurance Desk of the Hospital.
  3. Pre-Authorization Form: Fill out a Pre-Authorization Claim Form, which the hospital sends to the Insurance Company for approval.
  4. Approval from Insurance Company: The Insurance Company reviews the form and, if the claim is admissible, provides approval for Cashless Treatment.
  5. Receive Treatment: The Policyholder avails treatment at the hospital without making any payment.
  6. Settlement: The Hospital sends the final bill to the Insurance Company, which settles the bill directly with the hospital, excluding any Non-Covered Expenses or Deductibles, which the Policyholder needs to pay.

Reimbursement Claims Settlement Process in a Health Insurance Policy

Reimbursement Claims Settlement Process involves paying for medical expenses out of pocket and then claiming a Reimbursement from the Insurance Company. If the Policyholder chooses a non-network hospital, he will have to opt for Reimbursement Claim Settlement. The Reimbursement Claim Settlement Process is listed below:

  1. Receive Treatment: Pay for the treatment at the hospital
  2. Collect Documents: Obtain all necessary documents, including bills, receipts, discharge summaries, and medical reports.
  3. Submit Claim Form: Fill out the Insurance Company’s Claim Form and submit it to the Insurance Company along with the necessary documents.
  4. Insurance Company Review: The Insurance Company will verify the Claim Details, ask for additional documents if required and will approve or reject the Claim.
  5. Approval and Payment: The approved Claim Amount gets credited directly to the Bank Account of the Insured.

What are the documents required for a Reimbursement Claim under a Health Insurance Policy?

The Insured needs to submit the following documents to the Insurance Company to avail Reimbursement Claim Settlement under the Policy:

  1. ID Proof: A copy of the Patient’s ID proof (e.g., Aadhaar Card, Pan Card, Passport).
  2. Claim Form: Duly filled and signed Claim Form provided by the Insurance Company.
  3. Hospital Discharge Summary: A Discharge Summary mentioning the Treatment received and the duration of hospitalization.
  4. Hospital Bills and Receipts: Original Hospital Bills and Payment Receipts, including break-up of charges.
  5. Pharmacy Bills: Original bills for medicines purchased, along with prescriptions.
  6. Doctor’s Prescription and Consultation Papers: Prescriptions and Consultation Papers from the treating doctor.
  7. Pre- and Post-Hospitalization Bills: Bills and Receipts for expenses incurred before admission and after discharge from the hospital, as per the policy terms.
  8. Diagnostic Reports: Original Diagnostic Test Reports (e.g., X-rays, blood tests, MRI scans) along with receipts.
  9. Bank Details: Bank Account details for reimbursement, often including a canceled cheque.

Compare and Get the Best Health Insurance Plans with Qian!

Qian Insurance Broking LLP is a leading Insurance Broker In India focused on providing quality advice in the insurance space. We have tie-ups with leading Insurance Companies so that you can choose from a range of Health Insurance Policies depending on your budget and requirements. We assist you with appropriate coverages as well as Claim Settlement Process for your Health Insurance Policy. Get the Best Quote for Health Insurance Policies with Qian. You can get in touch with us via email at insurance@qian.co.in or call us on 022-35134695. We would be glad to assist you.

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Hemik of Qian is knowledgable, prompt and very professional - highly recommended. I had to claim for a critical illness under my health insurance policy and Qian’s assistance with the claims process and advice on how to deal with the insurer was invaluable.

Niyati Shah