17 Things to Consider While Buying Health Insurance

What Things to Consider While Buying Health Insurance in India?

The pointers below will help you select health insurance plan that resonates with the healthcare needs of both you and your family. Some of the crucial things to consider before buying medical insurance are as follows:

1. Sum Insured

   When purchasing a mediclaim plan, you must check the sum insured, which is the maximum amount your health insurance provider will pay for medical expenses during the policy term. It is crucial to assess your needs and choose a sum insured that aligns with your potential medical costs, and lifestyle. For instance, if you live in a metropolitan city where healthcare costs are higher, opting for a higher sum insured is advisable.

2. Waiting Period Clause

   While purchasing a health insurance plan for yourself or your family, you must always check the clause related to waiting period. During this period, the insurer does not accept any claims concerning any specific illnesses or pre-existing diseases. The waiting period can range from 24 months to 36 months, as per the insurer and the plan you choose.

   Diseases like blood pressure, diabetes, and thyroid, among many others, are applicable under the waiting period clause. Therefore, it is in your best interest to compare and choose a medical insurance plan with the lowest waiting period.

3. Pre and Post-Hospitalisation Cover

   Many times, even a short stay at the hospital can run into more than what an average person can afford. Therefore, a critical point to check before purchasing a mediclaim policy is to ensure that pre and post-hospitalisation cover is provided.

   Pre-hospitalisation charges include consultation fees and diagnostic tests done by the hospital and are covered for up to 30, 60 or 90 days before hospital admission. On the other hand, post-hospitalisation costs like ambulance expenses, medical tests, medicines, etc., are covered for up to 60, 90 or 180 days after you have been discharged from the hospital.

4. Restoration Benefit

   Restoration benefit is a useful feature where the insurance company restores your entire sum insured if it gets used up during a claim. For instance, if your policy has a coverage of ₹5 lakhs and you use it all for one treatment, the insurer will refill the amount, allowing you to claim again for other medical needs during the same policy year. This is especially beneficial for families or individuals prone to multiple health issues or accidents in a year.

5. Co-payment Clause

   While investing in a mediclaim policy, you must check the co-payment clause. As per this clause, the policyholder must pay a fixed percentage of the hospital bill. Health policies with co-payment clause are cheaper but provide less coverage since you will pay a significant part of the bill yourself. A few insurance providers make co-payments necessary, while others make it optional. So, make sure you review this clause carefully before buying a policy.

6. Day Care Procedures

   You should check the number of day care treatments covered under your health plan. These procedures only require hospitalisation for 24 hours. Some of the treatments included in day care procedures are radiotherapy for cancer, cataract surgery, dialysis, etc. Depending on your current health conditions, you may go for a mediclaim policy that covers maximum day care treatments.

7. Specific Treatments & Diseases

   Another important consideration while buying a mediclaim policy is coverage for specific treatments and diseases. It is especially important if you have pre-existing conditions or anticipate the need for specialised treatments. Most health insurance companies in India impose waiting periods of up to 3 years or caps on coverage for certain procedures like joint replacements or cataract surgeries. So, it is important to understand the coverage of such treatments before committing to a plan.

8. Room Rent Capping

   Room rent in health insurance pay off the room rent charges, including ICU, single room, etc. Many insurance providers set an upper limit on the room rent according to the policyholder's health policy and it can change as per the type of room selected. It is always advisable that you opt for a medical insurance plan with no room rent capping for a better experience.

9. Sub-limits

   You must be aware of sub-limits within the health policy. Sub-limits are caps on expenses like room rent, ICU charges, or specific treatments. For example, a policy may allow only a certain amount per day for hospitalisation, which could lead to out-of-pocket expenses if your costs exceed the limit. So, if flexibility is important to you, look for plans with minimal or no sub-limits.

10. No Claim Bonus

    A No Claim Bonus (NCB) included in your health insurance policy is a discount your insurer offers in return for claim-free years. Specifically, the basic coverage amount is increased during policy renewal.

    For example, you have a policy of ₹6 lakh, and there were no claims for two years. And the health insurance company provides around 10% of the no-claim bonus every year. Therefore, at the end of 2-years of policy tenure, you get 20% of NCB, which will keep increasing for subsequent years. The higher the percentage of NCB, the more you can benefit.

11. Preventive Health Check-ups

    Many insurers offer preventive health check-ups as part of the policy benefits, which can include free annual or bi-annual diagnostic tests. These help in the early detection of illnesses, ensuring better health management at no extra cost. You must try to look for policies that include this feature so that you can stay proactive about your well-being.

12. Exclusions

    Exclusions are the medical expenses or conditions not covered by the health insurance policy. Some of the common health insurance exclusions include cosmetic procedures, injuries due to self-harm, substance abuse, or pre-existing conditions during the waiting period. Knowing what is not covered under the mediclaim policy will help you avoid claim rejections later.

13. Riders/Add-on Covers

    If the base medical insurance policy does not provide adequate coverage, you can enhance it to a certain extent by adding health insurance riders. Some of the most common add-ons in health insurance are maternity cover, room rent waiver, global health cover, or hospital cash cover. As per the regulations set by Insurance Regulatory and Development Authority of India (IRDAI), the composite premium of all the add-ons included with the primary health policy should not exceed 30% of the original premium amount.

    For example, if Rahul has a health insurance policy with a co-payment of 10% and his hospital bill comes out to be ₹5 lakh, then he would need to pay ₹50,000 out of his own pocket and the remaining ₹4.5 lakh will be paid by his insurer. Therefore, choosing medical insurance with a co-payment is advisable only if you can pay off the remaining claim amount on your own.

14. Modern Treatment Cover

    Modern treatments like stem cell therapy, immunotherapy, deep brain stimulation, and robotic surgeries can be expensive. When purchasing a medical plan, it is essential to check for the inclusion of such new-age treatments. You can include them as an add-on cover to avoid out-of-pocket expenses if they are not included in your base policy.

15. Alternative Treatments

    For those who prefer or rely on alternative treatments like Ayurveda, Yoga, Unani, Siddha, or Homeopathy (AYUSH), it is worth checking if the policy covers such treatments. Many insurers include this coverage, but the extent and conditions vary depending upon the plan.

16. Quick Claim Settlement Turn Around Time (TAT)

    While choosing a health insurance plan, you may need to research the insurer's claim settlement history comprehensively. The best way to do so is to check the insurer's Claim Settlement Ratio (CSR) and the reviews provided by previous customers online.

17. Reputation of the Insurer

    Last but not least, check the reputation of the insurance company before finalising your health policy. You can do so by researching the insurer's CSR, online customer reviews, and service quality. A company with a high CSR and positive reviews ensures a hassle-free experience during medical emergencies.