Points to Check While Buying a Health Insurance Policy?

Purchasing a policy before any prior knowledge is like going to an exam without preparation. And if you fail, the loss only will be yours in both cases.

However, it may happen that you pay a lot of premium towards your health insurance policy but when it comes to claiming the policy your claim may get partially or fully rejected. If you are not aware of the clauses of your policy.

So, making a decision of purchasing health insurance is hard, and reading the policy is harder. Here with different case studies, it is explained what these terms and clauses actually mean.

Co-Payment Clause

Co-pay is a percentage which an insured person pays irrespective of the claim amount. Example: Mr Rahul takes a health insurance policy from XYZ company. Due to some health issue, he had to claim it. His bill total amounts to ₹5 lakhs.

Here Mr Rahul thinks that the claim is going to be fully settled by the company. This is a turning point, during settlement he has come to know about a co-pay clause which exists in his insurance policy. He didn’t read it during signing the insurance papers.

It mentions a 20% co-payment, which means out of the total bill amount only 80% will be settled by the company and 20% will have to be settled by Mr Rahul.

So always check all clauses before taking health insurance. Both sides of co-payment clause:

• Positive – You have to pay a comparatively lower insurance premium.

• Negative – If the hospital bill is pretty high you may have to shell out a big amount at the time of settling the bill.

Zonal Co-Payment Clause

Your health and sum insured are not the only factors which decide your premium. Your city also matters. India is divided into 3 zones as per the population.

Zone A	Zone B	Zone C
​Delhi/NCR, Mumbai (including Navi Mumbai, Thane and Kalyan)	​Hyderabad, Secunderabad, Bangalore, Kolkata, Ahmedabad, Vadodara, Chennai, Pune and Surat.	​All Cities apart from A & B belong to Zone C

See how your city of treatment will increase your premium. Let’s again take the example of Mr Rahul.

He lives in Zone C and the insurance company tell him to take his medical treatment in the same zone. In these cities medical treatments are comparatively lower and this is the reason why they are okay to collect a lower premium amount.

But Mr Rahul takes his treatment in Zone A, where charges are comparatively high. If he takes the treatment outside the zone which is defined in the insurance policy in that case the zonal co-payment clause will come into the picture whereby whatever the medical bill that will be split as whatever percentage is mentioned in the policy.

Note: Co-pay clause and zonal co-pay clause they may either co-exist in your policy or it could be either or it could be none of them as well.

Permanent Exclusion

The new and current policyholders should check the inclusions and exclusions of their plan. All these details are clearly mentioned in the policy papers.

The Insurance Regulatory and Development Authority of India (IRDAI) has created a list that insurers do not have to provide coverage. Check some of these below:

• Adventure sports activities

• Any drug or narcotics abuse

• Cosmetic surgery

• Treatment for self-harm

• Infertility

• Dental treatments (unless the dental injury results from an accident)

Note: These are some common exclusions. Some health insurance companies provide coverage for these conditions. Read the clauses of your health insurance to know the scope of your health insurance.

Waiting Period Clause

A waiting period refers to the duration before which certain health insurance will not be covered. Go for a policy with minimal waiting period, so you can avail coverage for all diseases.

Understand the concept of waiting period with this example. Mr. Rahul takes an insurance policy and after signing up for that within 4-5 days he is detected with Asthma. In this situation, the waiting period will be different as per the category of disease.

1) Illness Detected After Commencement of Policy

Waiting period of 30 days from the policy commencement date (except accidental claims if the same is provided). It can vary as per different policies.

2) Pre-Existing Illness

Check waiting period in policy, there are some diseases which have longer waiting periods such as 2 years for cataracts. Generally premiums will be higher because insurance companies know that there will be outflow at their end.

You must be wondering that there are so many clauses, how would I choose the best health insurance?

So, try Ditto, they tell you what they would choose if they were you. Take their advice Ditto! It is backed by Zerodha (check how it can helps you to start your investment journey within lowest market price).

Room Rent Restrictions

Certain insurance policies mention that most services rendered in your room, such as doctor’s fees, consultant fees, and diagnostic exams, will not be fully covered if you are choosing a room higher than the room limit which is mentioned in your insurance policy.

Example: Mr Rahul’s policy clearly mentioned that the room rent limit is ₹10,000 but he chooses to go ahead with a room rent of rupees ₹20,000. Here only half of the bill will be covered by the insurance company and half will have to be paid by Mr Rahul.

So be aware that if there is a limit then the entire bill might not be settled by the insurance company if you exceed the room rent limit.

Note: Better choice, to select an insurance company which doesn’t have such restrictions.

Cashless Claims

Depending on the policy cashless claim can be taken for both planned and unplanned treatments. The process for each kind is different.

Unplanned Treatments

Contact the insurance provider through customer care. After getting the details of network hospitals choose which one you prefer.

Planned Treatments

In this case, two to three days prior to the decision, you have to go first to the insurance desk at the hospital, which is in the network of that insurance company. After evaluating and verifying all information, the insurance provider will inform the concerned hospital.

Submit the following documents in both cases:

• Health card provided by insurance provider

• Submit a copy of insurance policy

• Pre-authorization letter

• ID proof

• Initial diagnostic report

• Claims process

Or any other documents if they are demanding. Submit all these documents and if the pre-order is done then you don’t need to pay even a one-rupee while you are being discharged.

Reimbursement Claims

In this process, insured people have to pay medical expenses from their pocket and once you get discharged and treatment gets complete. The process will start if you submit all the necessary documents mentioned in the policy.

Note: Whenever the patient is admitted within 24 hours from the date of admission you have to intimate the same to insurance company, if you don’t do so 24 hours laps, then it will be more of a reimbursement rather than a cashless claim.

Claim Rejection

The insurance company has to accept or reject the claim within 30 days of submitting the last document. What if the claim is rejected:

• Drop an email to the grievance redressal cell of your insurance company. If you don’t receive a reply within 15 days or if you’re not satisfied with the reply.

• Reach the Insurance Ombudsman. Ombudsman is a person who works as a mediator between an insured person and a company.

• If still you are not happy with this approach IRDAI (Insurance Regulatory Development Authority of India). You can call on 18004254732 or drop an email at complaints@irdai.gov.in.

• If you are still not satisfied with all this then you can knock on the door of the court.

To avoid this situation, choose an insurance policy correctly and go for a good consultation. Choose Ditto because they have no spam policy.