Mediclaim or Health Insurance is way of covering yourself and your
family against any medical emergency arising out of any diseases or illness or
accident. Not to have adequate health insurance cover is a very serious matter as
serious illness could be catastrophic to your financial wellbeing therefore it
is imperative you have adequate medical coverage along with life cover. But
truly speaking how many of you are really serious when you plan to buy new health
insurance plan? The awareness to buy
health insurance is increasing but do you devote reasonable time to research
and compare the features of the plan before finalising the plan? Buying
adequate and right health insurance is necessity of life.
I have received a call from one of my relative stating that all
companies are fake and don’t pay the full claim amount when needed. He was paid
Rs. 23,000 against the total hospital bill of around Rs. 36,000. I went to meet
him and checked the policy document and explained him why he got lesser amount.
I convinced him that company was right in paying the lesser amount and the
fault was of his agent who did not make him aware of some of the provisions in
the plan. The same applies to all of us as we come to know when actual need
arises. It is important to now the provisions in advance which can reduce your
claim amount.
It is very surprising to know that most of the people think that the
plan of one company is similar to the plan of other company and decide buying a
health plan only on the basis of the premium payable. This is not the correct
way of buying health insurance. The most important thing before buying health
plan is to know the features which can affect your claim amount. You have to do
some home work on the same and know all the exclusions and restrictions on the
claim before finalising the health plan. Buying health insurance plan without
knowing the dangerous provisions can really hit you badly when the actual claim
comes. The following are the two major clauses you must read carefully before
signing the application form. The premium comparison should be the last
criteria for selecting any health insurance plan.
1) Room Rent Sublimit:
This
is the most dangerous provision in health insurance policy where the claim
amount is decided on the basis of room rent you stayed in while hospitalised
for some illness. The sublimit is per day and is fixed at percentage of sum
assured. Mostly it is 1% of the sum assured. There is also upper cap of room
rent around Rs. 3,000 to Rs. 5,000 per day depending on plan to plan. The room
rent sublimit is the ceiling in the policy on room rent payable per day in which
you are supposed to stay when you or any of your family members is hospitalised.
As we all know hospitals have different types of rooms available like general
ward, twin sharing room and single room. The charges of any illness is decided
on the basis of room you opt even though there is no difference in treatment and
medicines given and even the doctor is same. This simply means in case you stay in a room costing higher than sub-limit,
all other hospital expenses will also be reduced proportionately by Insurance Company
on the basis of what you would have incurred had you stayed in a room that
costs below your room rent sublimit. In other words you are unlikely to
get the full amount of claim even if the claim amount is well below actual sum
assured.
2) Co-Payment:
There
are some policies available in the market in which co-payments are required to
be paid by policy holder. The co-pay ranges from 10% to 20% of the claim amount
in normal polcies but in some senior citizen plan the %age is even 30 to 40%.
Co-payment means part of the claim is to be compulsorily borne by the policy
holder. There are two types of co pay is levied. Co-pay is levied when you or any of the
family members is hospitalised in any non-network hospitals or it is applicable
compulsorily for claims made in case patient is of 65 years or more. If you
don’t to know this provision well before you buy any health insurance plan then
you will have to bear part of the claim every time when the claim arises. Again
you will not get the full claim amount even if the claim amount is well below
sum assured. There are options to waive the copayment in some cases if you pay
additional premium. You need to check this before buying a plan.
Is
there any solution to avoid these provisions? The answer is Yes. If you are
looking out to buy a fresh mediclaim policy, avoid any policy that has such
restrictions. There are around 25 companies which offer health insurance in
India. You have too many options available at present and many companies do not
have such restrictions in the plan. All the details related to plans are now also
available easily on net and now it’s your duty to do some work so that there is
no hassle at the time of claim. If you already have such a policy, then use the
recent portability guidelines to shift to any insurance company that does not
have such restrictions. The portability is a good option but it’s not
mandatory for new company to accept the proposal. The new company has right to
reject the portability request. It will be difficult for you to port the plan
if you are 45 years and above or have made claims in earlier years. The new
company to whom the portability request is given may not be willing to accept
your proposal due to higher risk. In such cases you will have no option but to continue
with older company and also plan for a medical contingency fund to deal with
these extra expenses that are not reimbursable.
It
is always advisable to disclose all the facts correctly while applying for
fresh insurance plan including bad habits and health history if any so that
claim is not rejected in future. You must also fill the proposal form yourself
and it is not advisable to just sign the form and give blank form to any agent.
If we devote some time before buying any health insurance plan then definitely
there won’t be any problem when the actual need arises.
This article first appeared at indianotes.com on 5th October'2015
http://www.indianotes.com/Finance-How-to/Provisions-that-can-reduce-claim-amount-in-Mediclaim/197581/4/TI
