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What is Health Insurance

Health insurance is a security layer that protects a patient from financial burden at the time of any medical treatment, hospitalization, or surgery. The insurance product, referred to as Mediclaim in India, enables the insured to seek cashless treatment at network or empanelled hospitals. In case, the patient incurs some or all the expenses, then the amount is reimbursed by the insurance company to the patient, as per the limit of the policy.

In technical terms, the person who takes the insurance is referred to as the insured. A premium or a fixed amount is paid to the insurance company for the cover. The premium can be paid monthly, quarterly, or annually. Health cover is accorded as per the insurance plan, and Health Insurance Companies offer a plethora of plans to choose from.

A Health Insurance policy is a necessary instrument that enables patients to meet the soaring costs of hospitalization required due to injury or illness. Medical costs include buying medicines, doctor's visits, diagnostic tests, surgeries, and hospitalization. These costs can cripple a family's finances, but with the right health insurance cover, it is possible to pay for treatment costing more than a year's salary. Don't let the massive costs involved with getting treated become a hindrance to seeking the right care for a loved one.

Not sure of which health insurance policy will be perfect for you? We are here to help clear all doubts you may have, including but not limited to :

  • Which health plan will meet your needs?
  • What is the best cover you can opt for?
  • Should you invest in all eventualities?
  • Can pre-existing diseases be covered?
  • How do I buy an insurance cover for a family member?
  • Are there illnesses which will be excluded?

While you may be in the pink of health today, who knows what the future has in store for you. Here we are listing the benefits of buying health insurance to help you make an informed decision.

Even though the main benefits of health insurance are financial support in case of medical treatment or in the event of hospitalization, there are other major benefits associated with health insurance policies, which may vary with the insurance provider :

  • Cashless hospitalization
  • Coverage of Pre-and post-hospitalisation expenses within 30 to 60 days from the day of hospitalisation, depending on the plan purchased
  • Coverage of accidental emergencies from the day one
  • Certain day care treatment or procedures as an out-patient for a continuous period of less than 24 hours
  • Coverage of nursing expenses and fees of surgeon, physician, consultant, specialists
  • Cover for outpatient department (OPD) expenses
  • Tax exemption under Section 80D
  • Coverage of maternity and vaccination expenses of the new-born depending on the plan and / or provider
  • Coverage of ambulances charges within a limit
  • Regular Health Check ups

Some major inclusions in a health insurance policy are as follows :

  • Cost of hospitalization
  • Pre- and post-hospitalization expenses
  • No Claim Bonus
  • Cashless treatment
  • 24x7 assistance with regards to your policy
  • Deductibles to reduce premium

It is important to realize that inclusions will vary from one provider to the next and from plan to plan. Contact us if you are still struggling with questions or information.

There are certain ailments and conditions that health insurance plans generally do not cover. Here, we are sharing the major exclusions.

Pre-existing conditions

You should declare pre-existing conditions at the time of buying the plan. All plans have a lock-in period of about two to four years for pre-existing conditions.

Alternative and Holistic Therapies

Most insurance providers do not offer coverage for holistic and alternative therapies. This is because these therapies are unregulated and come with different costs, making it difficult for insurance provider to fix a rate.

Cosmetic Treatments

you want to have plastic surgery to look and feel better, it will not be covered by your health insurance. The only thing that your plan will cover is when the treatment is medically recommended after an accident or injury.

Lifestyle Diseases

Certain lifestyle habits like smoking and drinking can lead to lifestyle diseases, like cancer and cirrhosis of the liver. Health insurance does not cover these diseases.

Pregnancy and Childbirth

Most health insurance policies do not offer cover for pregnancy and childbirth. Also, they do not provide coverage for infertility treatments and abortions.

Diagnostic Tests

If you undergo diagnostic tests, the same will not be covered by the insurer unless the positive results of the tests require hospitalization.

When it comes to health insurance there are two main types of plans you will find. One is the individual health insurance plan and the other is a family floater plan. An individual health plan covers only a single individual while a family floater one covers all the members of a policy under the sum insured.

Individual Health Insurance

It covers individuals but does not pay for hospitalization and treatment of pre-existing health conditions during the waiting period of one to four years. Individuals under the age of 45 years, may not have to undergo a medical check-up. It is dependent on the health insurance policy provider and plan chosen.

Family Health Insurance

This health insurance policy offers coverage to the entire family. All members of the family covered by the policy are insured, and there is usually no limit on how much can be availed by one single member of the family. Most health insurance plans in India insure the primary member, spouse and two children below the age of 21-25 years. However, some companies extend the cover to include parents and siblings.

Parents Health Insurance

Taking care of parents' health is always a priority, and Parents Health Insurance lets you do just that. The plan is for parents above 50 years of age. As per need, you can take the plan as a family floater or for an individual parent.

Child Health Insurance

Children are more susceptible to illness than young adults and hence, taking a Child Health Insurance is important. Minor children are covered under Family Floater Plans or if you want, you can take individual plans for each of your children. The entry age varies as per the plan, beginning from 1 day to 90 days, while the maximum age can be from 21-25 years.

Heart Patient Health Insurance

If you are already diagnosed with a cardiovascular disease, a heart-patient or a cardiac-specific health insurance will help with your care. Available as individual plans, some of the health insurance companies may cover a spouse. Inclusions of cardiac-specific health plans are heart contingencies, pre- and post-hospitalization, ambulance expenses and day-care procedures, etc.

Maternity Insurance

Pregnancy brings joy on one hand, and expenses on the other. A Maternity Insurance is important to help with the impending expenses as the inclusions, apart from the pre- and post-natal expenses, will usually cover ambulance charges, delivery expenses, first year vaccinations and new born baby cover.

Diabetes Insurance

Since Diabetes is classified under pre-existing condition, it is not covered under general health insurance plans. You need Diabetes Insurance plan to help meet the expenses related to the disease. Most people know that diabetes is either Type 1 or Type 2, and not all health insurance companies cover Type 2 Diabetes. However, some companies are known to include amputation and dialysis expenses in their cover.

Senior Citizen Health Insurance

Seniors between the ages of 60 and 80 can take an insurance cover of up to 5 lacs. Medical check-up is essential to take this health policy. Pre-existing health conditions usually get covered after 18 to 24 months, based on the insurance company's terms and conditions.

Cancer Health Insurance

A cancer plan is available only for a specified tenure, and a benefit is paid if the insured is diagnosed with minor or major stage of cancer. What makes cancer health insurance unique is that payments are related to the stage of the disease. A no-claim bonus is applicable on the policy.

Travel Health Insurance

This insurance reimburses the insured in case of hospitalization during a vacation, or business or leisure travel. There are many packages that the person can select based on their needs. This plan helps to take care of medical emergencies while you are away from home.

Dengue Care Health Insurance

With the increasing number of patients afflicted by Dengue in India, health insurance companies are now offering to cover treatment for dengue.

As is obvious, you can find a range of health insurance plans for your medical requirements, right from ones that cover the cost of hospitalization and critical care for emergencies and life-threatening diseases.

The Insurance Regulatory and Development Authority of India (IRDA) publishes a list of insurance companies with their rating. The IRDA uses a range of parameters to rate health insurance companies, including the incurred claim ratio, the benefits offered to customers and the performance of the companies. Based on those parameters, here is a list of the top 10 health insurance companies in India :

Apollo Munich Health Insurance Company Limited

This health insurance company is a joint venture between Apollo Hospitals Group and Munich Health, which is a subsidiary of Munich Re, a German company. Currently, it is considered the best health insurance company in India, thanks to its impressive incurred claim ratio of 64.61%. In addition, it offers customers other benefits, like health insurance portability and lifelong renewal of the health plans.

Star Health and Allied Insurance Company

This company is a joint venture between ETA Ascon, Oman Health Insurance and few other experienced health insurance providers in India. It has incurred claim ratio of about 53.81%. What makes this insurance provider unique is that it has an in-house third-party administrator (TPA) to handles cashless medical treatments and hospitalizations. It also offers disease-specific insurance plans like Star NetPlus for patients who are HIV+ and Diabetes Safe for people diagnosed with diabetes.

Max Bupa Health Insurance Company Limited

This is another joint venture; this time between Bupa Group and Max India Limited. The company has incurred claim ratio of about 59.53% and is renowned for having health insurance plans for all age groups, including senior citizens.

ICICI Lombard General Insurance Company Limited

Though a general insurance company, ICICI Lombard offers health insurance plans. The most sought-after plan is called Health Advantage. This plan offers full coverage for any expense that you incur in a medical emergency. The plan covers dental expenses, hospitalization, ambulance, and room rent, but to a certain limit. It boasts an incurred claim ratio of 87.38%.

Religare Health Insurance Company Limited

Although a new entrant in the realm of health insurance, Religare Health Insurance Company has impressed everyone with its tremendous growth. It is a joint venture between Union Bank, Religare Enterprises Limited and Corporation Bank. Fortis Hospitals' founders promote this insurance company. It has an incurred claim ratio of 89.40%.

Cigna TTK Health Insurance Company Limited

This health insurance company started operations in 2014. However, in these few years, it has become a force to reckon with. It has incurred claim ratio of 78.66%, which is considered excellent considering that it is a newbie in the world of health insurance.

Bajaj Allianz General Insurance Company Limited

A joint venture between Allianz SE and Bajaj Finserv Limited, Bajaj Allianz General Insurance Company Limited offers a few Mediclaim policies, like Star Package, Silver Health, and Health Guard. The company has an incurred claim ratio of 72.30%. It was the first insurance provider in India to offer captive TPA services that come with certain benefits for customers.

New India Assurance Company Limited

This insurance provider is 100% owned by the company and has been around for nearly a century. It began its operations back in 1919, and is renowned for its customer-friendly mediclaim policy. What makes its health insurance unique is that the provider gives different ratings for metros compared to smaller towns and Tier II and III cities. It has incurred claim ratio of 87.84%.

Oriental Insurance Company Limited

Oriental Insurance Company Limited is also a public-sector insurance company that is fully owned by the Indian government. This general insurance company offers affordable health insurance plans. Customers, who buy health insurance, don't need to have a medical test before purchasing the plan until the age of 60. This is completely different from other health insurance companies that mandate buyers to have a health check-up if they are over 45 years of age. It has an incurred claim ratio of 83.71%.

National Insurance Company Limited

National Insurance Company Limited is a general insurance company that is wholly owned by the government. It offers several health insurance plans, and out of these, the most popular is Varishtha Mediclaim designed for senior citizens. With an operating history of more than 100 years, this insurance provider has an incurred claim ratio of 95.28%.

Paybima is here to help you compare and choose the right health care partner for your needs. However, you need to understand what you need before taking a health insurance policy.

Here are the two basic things that you should look at before you approach a health insurance company :

Evaluate Your Needs

Are you at risk for a cardiovascular disease or diabetes? Are you not getting enough exercise and working late, making you prone to stress? These are just a couple of the many questions you should answer to evaluate your need. Look at your family history to know the diseases you are genetically inclined towards. This will help you shortlist the plans and policies you can take.

Determine Your Budget

You should be comfortable paying your health insurance premiums. It should not be a financial struggle. However, we always suggest, weigh in the premium against the cost of medical expenditure!

It is also necessary to evaluate the conditions applicable for your policy. If you have any concerns, we, at Paybima, are always eager to provide answers.

There are some factors that you need to consider before you buy health insurance. These include the following :

Select the Sum Assured Prudently

The sum assured will depend upon your ability to pay a premium. However, factor in inflationary costs of hospitalization and surgery when choosing the sum assured. Be sure to compare health insurance plans online before making the final call.

Read the Fine Print

Before you buy health insurance, read the terms and conditions, carefully. This will enable you to figure out what exactly the insurance covers and when. As a result, you can determine whether the insurance policy is apt for you.

Insurance Cap

Health insurance premiums affect co-payments and sub-limits. Make sure you understand these before you purchase the health plan. It is prudent to remember that co-payments, cap, and sub-limits will have an impact on the plan benefits in the long-term.

Claim Settlement

Perhaps the most important factor to consider is the claim settlement record of the insurance company. Choose a company with a good record of settling claims. Request the insurance provider for their claim settlement ratio so that you can determine whether it is the right provider for your healthcare needs.

The Health Insurance Cover

While health insurance premiums are important, don't let the premium amount be your sole criterion for choosing a plan. Instead, you should find out what the insurance covers so that you can determine whether it can meet your needs. Cashless hospitalization, post-hospitalization and surgery are some things that should be covered by your health insurance plan.

The Number of Years It Offers Protection

This aspect is linked to the renewability of the plan. Usually, you renew a Mediclaim policy annually to keep it in continuation. If you don't renew it, the policy lapses, and you lose any benefits it has to offer. Hence, find out how and when you need to renew the plan and what benefits you can avail with a timely renewable.

Partner Hospitals

Make sure you carefully go through the list of impanelled hospitals. Take note of the ones nearest to your place of stay and work, and check out the specialist care they offer. Ascertain whether the partner hospitals will be able to cater to your healthcare needs.

Terms and Conditions Related to Premium Loading

A health insurance company sometimes endures higher losses than it anticipated. It minimizes the risk of losses by adding premium loading into health insurance policies. This increases the health insurance premiums each time you make a claim.

Dedicated Team

It is important that the health insurance provider has a dedicated team of professionals who handle questions and the claim settlement process. Most insurance companies use a TPA to manage claims and handle problems.

Check Family Size Covered in Family Floater Health Insurance

Family size varies and for this reason, most health insurance companies stipulate the number of dependents who can be covered by family health insurance. Make sure you understand this and select a plan that covers all your dependents, be it a spouse, children, siblings, or parents.

Health Insurance Portability

Health insurance portability allows you to opt for a new insurance provider without losing the benefits you have accrued with your existing company. The portability also lets you opt for better policies with another insurance provider. Usually, health insurance portability is free, but some providers may charge you a fee.

Waiting Period for Pre-existing Health Condition

If you have any pre-existing illness, there will be a waiting period. Usually, the waiting period is 30 days from the day your insurance policy is initiated and is a one-time procedure. An insurance company can deny a claim if the insured is hospitalized during the waiting period. However, it will approve the claim in case it is an emergency.

Top Up Plans

Instead of opting for another plan, you can choose a top-up plan that increases the premium and the cover of an existing plan.

Restore Benefit Option

With this option, you can restore the sum assured if you have used it up already. However, it is prudent to remember that once you restore the sum assured, it cannot be used for the same ailment that caused you to reach the limit.

Compare Health Insurance Premiums with benefits

Don't compare health insurance premiums on their own. Instead, compare the premiums to the features offered. This way, you will be able to ascertain whether you will use all the features. If not, you should look for a policy that has features that you will use.

Still confused? You can get in touch with us to understand why investing in a health insurance plan Is a good idea.

Read More: What Factors one should consider before buying health insurance?

Health insurance eligibility criteria are very simple and straightforward. Typically, most insurance providers have the following eligibility criteria :

  • The person to be insured should between the ages of 18 and 65 years
  • Dependent children should be between three months and 21-25 years of age

At Paybima, you can check the eligibility criteria of the top health insurance providers in India at one page. But, do you know how to buy insurance? Read on to how to buy Health Insurance.

Today, you no longer have to visit the office of a health insurance company to purchase a policy. Here are the steps to buy the best health insurance cover online :

Step 1: Fill out your name, age, marital status, city, and the number of family members you want to insure. In addition, you will need to fill out your annual income and occupation. Request for a quote from the insurance provider.

Step 2: Compare terms and conditions of multiple health insurance policies to shortlist three to four policies.

Step 3: Trim the list to one and then check out the plan. You will need to fill out a health declaration form where you would need to give your medical history and occupation along with few other details.

Step 4: Check out the benefits offered by the plan and the add-ons that you can include with the existing benefits. Select the ones that you like.

Step 5: Use net banking, credit card or debit card to pay for the health insurance.

Step 6: You will receive a digitally signed copy of the policy. Take a print out and keep it safe.

When you buy health insurance online, you submit ID proof and other relevant documents. Some providers may make it necessary to undergo a medical check-up based on your age, occupation, and medical history. In such a case, you will have to submit the report when buying the policy.

Age-related documents

If you do not have a birth certificate, any valid document which clearly states your birth date will have to be provided – Birth cer10th and 12th Pass certificates, driving license, voter ID, Passport are valid.

Identity-related documents

Though Aadhaar has become the most important document related to identity in India, your passport, PAN card or driving license can suffice. A passport size photograph will have to be submitted.

Address-related documents

You need to submit proof of residence in the form of an Electricity bill, Passport, Driving license, which clearly states your permanent address.

Medical-related documents

You will have to undergo all the tests considered necessary by the insurance company and submit those reports.

Whenever you take out a policy, remember to renew it before it expires so that you can continue to enjoy the benefits.

Just like it is easy to buy health insurance online, it is simple and convenient to renew your health insurance plan online. You can use the following steps to renew your policy :

  • Use the username and password to log onto your account on Paybima
  • Click on your health insurance policy
  • Click on Renew policy tab
  • Fill out existing policy number and expiration date of the policy
  • Click Continue to reach the payment gateway. Make the payment using net banking, credit card or debit card
  • After your payment is successful, the insurance provider will issue a digital copy of your health insurance
  • Take a printout of the renewed health insurance plan and keep it safe

If you are wondering whether it is worthwhile to renew your health insurance, here are some benefits that you should be aware of :

  • No need to worry about the waiting period where you cannot file for claims and reimbursements
  • You are entitled to No Claim Bonus, provided you did not make a claim during the previous tenure of the plan. This bonus can be deducted from your premiums or can be used to increase the sum assured amount
  • Health insurance companies provide coverage for pre-existing health conditions after a waiting period of about three to four years. On-time insurance ensures this period keeps getting shorter. If you delay the renewal, the waiting period re-starts from the date of renewal, negating the waiting period from the previous years

When you opt for cashless treatment, you present the details of your health insurance policy to verify that the plan covers you. This will allow you to get cashless hospitalization and treatment if the ailment or condition is covered by your health plan.

After you get discharged, the hospital will send the relevant documents and bill to the insurer and the amount will be settled thereafter.

Claim Procedure for Planned Treatment

Typically, if you are going to the hospital for a planned treatment, it is mandatory to inform the insurer at least four days in advance. This will necessitate filling out the cashless claim request form and submitting it to the insurance provider through email, fax, or post. It is only after you complete this formality will the insurer inform the hospital and the treatment can go ahead.

On the day you go to the hospital, you will need to present the confirmation letter from the insurance company and your health insurance card to enjoy cashless treatmen.

Claim Procedure for Unplanned Treatment

An unplanned treatment is an emergency treatment required for maybe an accident or a stroke. Under such circumstances, you can visit the nearest partner hospital and show your health insurance card to get cashless treatment at the hospital.

The hospital usually fills out the cashless treatment form and dispatches it to the insurer on your behalf. On receiving the form, the insurance provider will issue an authorization letter, and the payment for the treatment will be settled directly between the insurance provider and the hospital - if it is covered and within the limits prescribed by the policy. If it is over and above the limit or not covered by the insurance, you will have to pay for the treatment yourself.

It is important to remember that you can get cashless treatment and hospitalization just in the network hospitals that are approved by your insurance company.

If you have treatment in a hospital that is not impanelled by the insurance company, you cannot use the cashless hospitalization and treatment facility. Here, you will have to foot the entire bill of the treatment and hospital stay and provide the original bills to the insurance company.

After examining the bills, the insurer will decide whether the plan covers the treatment. If yes, based on your sum assured, you will be reimbursed for the treatment. If the treatment is not covered, your request for reimbursement will be denied.

When you claim reimbursement from your health insurance provider, you will have to fill out a reimbursement health insurance claim form and submit the following documents along with the form :

  • Medical certificate duly signed by the doctor who treated you
  • Original discharge card issued by the hospital
  • Original bills and receipts
  • Prescriptions and cash memos from the pharmacy or hospital
  • Tests and investigations conducted
  • Invoice / sticker for implants if used in the surgery
  • If you meet with an accident and require an emergency treatment, you will have to submit either Medico Legal Certificate or FIR registered by the police
  • Cancelled cheque of insured bank account to make the health insurance claim payment through NEFT

If you need any further information and clarification regarding any aspect of health insurance in India, please do not hesitate to contact us!