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All you should know about health insurance before buying

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drjpatwa
If you compare health Insurance plans on Insurance web aggregator (Like policybazaar), you will find almost same features in all of them. So, you might get confused & fall in trap of cheapest plan or suggested by agent without knowing complete policy wording. So, here I am summarizing all you should know about health insurance plan with emphasis on hidden Terms & Condition. 1) No Claim Bonus (NCB) / Multiplier Benefit This is the benefit Insurer gives to customer for not taking claim in single year. Unlike vehicle insurance policy where NCB benefit is in terms of discount in subsequent renewal, in health insurance majority of time NCB is in the form of increased in Sum Insured (SI) (Coverage limit of your health insurance). Points to Note: - Rate of increase in sum insured limit will differ in different plans of same insurer & also from 1 insurer to another. Faster the rate, better it will be. E.g. Apollo Munich (Now HDFC Ergo) optima restore plan gives NCB as 50% increase in SI - Max. cap of increase in SI. Higher is better. Some plan gives max. upto 50%, some gives upto 100% - Penalty for taking claim. Whenever you take claim in a year, your insurer will penalize you for it (Usually by reducing accrued NCB by same rate as of in increase). No penalty or low penalty is better. E.g. Max bupa doesn’t penalize for taking claim - Majority of PSU insurer (National, united etc.) don’t provide this feature. - Best thing about NCB is, Increased in SI has no extra terms & condition & it is equivalent to your base plan with higher coverage. So your policy should have this benefit. 2) Restoration benefit / Refill benefit Agents sell policy saying total 10 lac coverage (5 Lac base SI + 5 lac restoration). Restoration benefit means once your SI (+ NCB, if any) get exhausted insurer will refill same amount as base SI (like 5 lac) once in a year. All hidden Terms & condition lies here. So, read policy wordings & don’t rely on agent. Like, - Some insurer has T&C that - Restoration can’t be used in same person with same disease (Not even complication of same disease) E.g. – Max Bupa E.g. Person detected with cancer & total bill (In single claim or multiple claim – like in chemotherapy cycle) goes above 5 lac, still he can’t get restoration benefit. - Can be used in same person, same disease but with gap of minimum 45 days - Single claim in policy year can’t exceed basic SI + NCB (Indirectly saying restoration can’t be used in single claim however it can be used in subsequent claim with gap of 45 days) – E.g. Apollo Munich My take is, don’t fall in trap of this benefit. If they are giving it at no additional cost, go for it. Because you can use it for other family members. 3) Co-pay Co-pay is the amount in percentage you have to pay out of your pocket for every claim. Usually co-pay plan is offered at reduced rate compare to normal plan to attract people. But never go for any plan, which has co-pay. Beware: Some insurer have same base plan but if you opt for discount, they will convert it to Co-pay plan. E.g. Religare. Religare offers 15% discount to customer who opt for co-pay feature under their Religare care plan. Some of agents, Including policybazaar (Which will always try to sell Religare plan) try to attract customers by saying we will offer 15% additional discount without telling about this Co-pay. (I myself fall in trap of policybazaar, thank god I was saved my research. I do complaint against them on twitter too) 4) Zone/Geography base charges This might find unusual but many companies levi Co-pay charges if you change your Zone for treatment. Like if you have taken policy in Agra & if u want to hospitalized in Delhi, then you have to co-pay 20% amount. E.g. Hdfc Ergo policy In few insurer, it is optional to choose zone wise charges. Don’t fall in trap of it to save few bucks. Because agent might give you Zone B policy at lower rate & you might end up paying 20% co-pay for taking treatment in Zone A. Choose Insurer which don’t have such geographical/Zonal restrictions. 5) Life-long renewal without Co-pay Some insurer put additional co-pay terms for renewal after age of 60/65 years. Avoid such plans. 6) Sub Limit or Capping Many policy have sub limits on Room rent, ICU charges, capping on cataract, Knee replacement surgery etc. If ur bill goes beyond these permissible limit, they will deduct all charges on pro-rata basis & not alone room charges (Like doctor consultation, laboratory charges, OT charges, procedure charges etc.) Also keep in mind that these sum limit of Room rent includes – Room charges, nursing charges, injection charges, Ventilator charges (if used in ICU) etc. So better to choose plan which don’t have sub limits or capping. 7) Pre/post Hospitalization Higher number of days coverage, better it is. Like Apollo optima restore gives 60 & 180 days pre/post benefit compare to others who usually gives 30 & 60 days respectively. 8) Free health check-up Don’t get lure with this free benefit. This freebie shouldn’t be prime deciding factor while taking plan. If this benefit is there it is better. 9) AYUSH Benefit If you want to get treatment for Ayurvedic/Homeopathy etc. check Aysuh benefit. Some insurer provide Aysuh benefit for full SI E.g. Max Some insurer provide Aysuh benefit with some capping like max. 20k/50K E.g. Religare Some insurer don’t provide Aysuh benefit E.g. Apollo Imp Point: This benefit is only available for hospitalization in Government AYUSH hospitals or NABH accredited private hospitals. Only few private AYUSH hospitals take NABH. 10) Stay healthy Discount Very nice initiative by some insurers (like Apollo, Hdfc etc.). If you stay healthy they will provide you additional discount at renewal. For which you have to download app/wear digital watch & they will calculate daily walking steps & give discount slab wise with max. 8-10%. Those who are already doing such exercise daily, will get this discount & for others this discount will lure to be healthy. 11) Waiting period for Pre-existing disease Pre-existing diseases are covered after 3-4 years (Max, Apollo 3 years, Star 4 years). Shorter the duration better it is. While for slow growing diseases waiting period is usually 2 years. 12) TPA (Third Party Administration) Many general insurance companies (like National, United etc.) don’t have their own medical team to verify claim details & they rely on TPA for claim settlement. So, customer has to deal with TPA first for claim & then TPA approved amount released by Insurer. While some other insurer (like Apollo, Hdfc, Religare, Max etc.) have their in-house settlement team & don’t have TPA, which fasten the process of claim & refund. Go for companies without TPA 13) Daily Cash benefit Over & above your actual claim amount, some insurer gives daily cash benefit for miscellaneous expenses but with lots of T & C like - Admission should be in network hospital, Minimum stay 48 hrs., Room should be twin sharing room etc. & upper cap is also there, Not valid for ICU admission - However if this benefit is there at no extra cost, its good. 14) Exclusion There are some common exclusion in each policy, which many are not aware. - Admission, discharge, record section, RMO, Administrative, registration, service charge etc. (Many corporate hospital levy Administrative service charge at whopping 15% of total bill amount excluding medicines & these charges are straight away rejected in claim - Cosmetic surgery - Experimental, unproven treatment - Hospitalization just for investigation or diagnosis - Circumcision - War like situation, Terrorism, Hazardous activity – like Scuba diving etc. - Dental / Eye treatment like Laser - HIV, STDs - Alcohol, substance abuse - Assisted Reproduction (IUI, IVF etc.), birth control related procedures - Obesity & its complication (Keep this thing in mind, anywhere during admission if doctor writes your diagnosis as Obesity – case gone. Your claim will be rejected) - Maternity (Some plans do offer this benefit but has long waiting period of 3 years), infertility, birth control treatment etc. - Non-medical expense (like cotton, loose gloves etc.) - Apart from this common list, many insurer have added some more exclusions (E.g. Some Specific medicines are excluded) & some black listed hospitals. Do check for it in policy wordings or I have highlighted such comapny specific unique exclusion in my google spread sheet, u can go through it. Apart from these following are excluded in majority policy (Except Apollo has recently added it in inclusion list) - Neurological diseases like Parkinson’s, Alzheimer’s disease etc. - Stem cell transplant - Robotic surgery, LASER, Light treatment (Remember if you are living in metro cities then some of sophisticated hospitals do have Da vinci Robot & they use it frequently – but your insurance won’t cover it) 15) Availability of Insurer / TPA office in your city - In case of reimbursement availability of Insurer nearby to you will be helpful for documentation & if any query arises. 16) Network hospital list - Don’t just check number of hospitals. It will be more or less same in each insurer. But most important thing is to check whether these hospitals are well-known & according to your preference or not. 17) Individual Vs. Family Floater If you take Individual health insurance for each family member, it will be costly affair compare to taking Family floater. Suppose three are 3 persons in Family (2 Adult & 1 Child) looking for Sum Insured of 5 lac. Simple reason to understand cost difference is because in Individual policy Insurer is liable to pay max. up to 15 lacs (If all 3 gets sick & put claim), while in family floater Max. liability is only 5 Lacs. However, as per my opinion there is rare possibility (Unless in accident) that all of the family members need it at a time. So, better to go with family floater plan with higher Sum Insured at same rate as compare to Individual plan. In family floater plan children are allowed only till they reach 21 year of age (E.g. Max) or 25 year of age (e.g. Apollo, HDFC). 18) Pricing Majority insurer increases price of premium in the slab of every 5 year. Like for age 31-35 premium remains same then increases at 36 age which remains same till 40 years. However Max is following increase in premium every year by 100-200 rs., unlike sudden rise of premium with age slab changes. So do check it. 19) Top-up / Super Top-up plan Rather than going for higher Sum insured in base policy, one should go with super top-up policy if person feels that Base policy is inadequate. Because these policies are cheap. Again all hidden T&C are there in these plans. So read carefully before buying it. Top-up policy – As the name suggests, it is top-up to your existing policy. Lets understand terminology first. Deductible Amount – It is the minimum amount one has to pay (Either through base policy or through their own) to get triggered top-up policy. Sum Insured – In top-up policy sum insured includes base sum insured also. E.g. Your base policy is 5 lac. You have taken top-up policy of 10 lacs. Deductible amount will be 5 lacs Sum Insured – 10 lacs Actual coverage in your top-up policy – 5 lacs (10 lacs- 5 lacs base policy) Now Important T&C in Top-up policy is you have to pay deductible amount during each claim separately to get triggered Top-up policy. E.g. You have taken 5 lac base + 10 lac Top-up policy (Here Actual coverage in top-up is 5 lac) Case 1: You get accident & your bill goes to 7 lac. Here, in single admission you have used deductible amount (Of 5 lacs), your top-up policy will get triggered & remaining 2 lacs will get paid from top-up plan. Case 2: You get dengue & bill of 4 lac has been settled from base policy. Now you have 1 lac remaining in base policy + 5 lac top-up. After few months you get accident & bill becomes 3 lac. In this case your top-up policy will not get triggered. Because as per T&C bill should be more than deductible amount (here 5 Lac) in single admission to get triggered top-up policy. Difference between Top-up & super top-up policy is that in super top-up policy they calculate deductible amount cumulatively. So, in above case 2, super top-up policy will pay remaining 2 lacs but not top-up policy. Super-top up policy is somewhat costly compare to top-up. But always buy Super-top & not Top-up policy. For easy comparison of all features of different company’s plan at one place, I have made Google Spread Sheet. This sheet will help everyone to compare & decide best policy for them. Those dimers who want it can request it here or pm me. Also I am in the process of making another similar sheet for comparison of Top-up / Super-top plan & also for special need plan Like maternity, cancer, cardiac, senior citizen Etc. Disclaimer: I am doctor by profession but I have interest & knowledge in Finance. Prime purpose is to help people & prevent victim of mis-selling of insurance. If u have any query, ask it here or Pm me.
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We are not SEBI/IRDA registered. The information provided herein is for education purposes only. We will not be responsible for any of your profit/loss with this channel's suggestions. Consult your financial advisor before making any decisions.

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Deal Lieutenant Deal Lieutenant
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Nice. Btw how good is New India Assurance?

Beacon Beacon
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You can go with it, if you have lots of patience.

At the time of discharge in cashless hospital, they will take minimum around 3-4 hrs. to 1 day also !!!

& for reimbursement claim, you have to wait for 1-3 months to get refund.

But you will get your money.

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Deal Subedar Deal Subedar
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thanks for the elaborate post. Any idea if there is a cover for maternity claim (I can only find in group policy but I am not employed so as individual hard to get)

Beacon Beacon
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Check Religare Joy today plan. They have lowest waiting period for maternity cover – Only 9 months waiting.

There are other plans but that have waiting period of 3-4 years.

However calculate Risk reward ratio for taking maternity cover.
E.g. Religare Joy today plan for 5 lac SI will cost around 75k for 3 years policy. It will cover max. 50K for mother & max. 50k for new born child.

Don’t take it otherwise, But also keep in mind that what if u can’t plan baby in 3 years (Due to Infertility or other reasons), u will loose huge amount of premium.

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Deal Subedar Deal Subedar
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Even as I said earlier Co like Alkem pharmaceutical Ltd have health insurance of Oriental insurance Ltd of psu . So you can think of it. That’s can be they found good . Macelods pharmaceutical Ltd had ( one of known person works there ) – Have new India assurance health insurance

Beacon Beacon
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Yes corporate do tie up with PSU. Even IBA (Indian Bank Association) has tie up with United for bank employees. But then they appoint dedicated persons to look after issues related to claim for that corporate. As a Individual we don't get that luxury. My father is having United policy for ex-bank employees. My mother had cancer twice in 2016 & again in 2019. So, I have extensive experience of dealing with PSU insurer. In 2016 TPA was DHS & we had overall good experience barring 1-2 small deduction. But in 2019-20 this time MDINDIA is TPA & despite there dedicated representatives are good, I am yet to get refund of around 50k for extra deductions they did & I challenged it with all proof. So, you can go with PSU. but calculate risk reward ratio & have lots of patience for follow up...
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Deal Cadet Deal Cadet
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Any specific reason or point for not having religare in your list? I am having Religare care plan from past 6 years. Family floater. @drjpatwa

Also is there option of health insurance transfer from one insurer to other along with ncb si?

Beacon Beacon
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Religare Care is good plan.
Reason why I skipped its name is because their owner got jailed last year & now new owner is there, which we don’t know, how well work.

Also this plan gives NCB max. To 50%, while other gives upto 100%.

So not wise for existing user like you to switched but for new policy, i personally will avoid it.

Ha ha. As per my knowledge No company gives benefit of increased SI due to NCB while porting.

Deal Newbie Deal Newbie
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Hi can you share your number I was looking for insurance so we can discuss one to one

Deal Subedar Deal Subedar
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Informative post. Thanks

Any evaluation of standalone critical illness or cancer plans?

Beacon Beacon
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Yet not evaluated those add-ons. But 1 hint. Do check stagging of such diseases covered in policy wordings. Because some times (particularly in term plan rider) they includes only stage 4 cancers etc.. Check for disease stagging for each disease before buying such add-ons.

If only last stagging diseases are covered then no meaning to buy it.

Deal Subedar Deal Subedar
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Way too long.
The sheer length terrifies me from reading it.

Beacon Beacon
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Ha ha. Better to read rather than regret at the time of claim…

Deal Newbie Deal Newbie
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I am completely impressed with your hard-working in getting all pros and cons for health insurance. Even I have done complete analysis before zeroing Aditya Birla Activ assure diamond plan. You will get upto 30% returns if you enroll activ health. It is similar to stay healthy discount. Hope this helps you.

PS. I am not a agent either have any direct relation with Aditya Birla

Beacon Beacon
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Thanks for pointing it out. Yes I read about it after ur recommendation, they do offer upto 30% discount for staying healthy.

To calculate it, they includes 2 things. 1 is daily steps that is clear but 2nd is they take health assessment & divide u in 3 category. Green, Amber & Red. How they divide u in 3 category is not clear.

But primia facie, this feature seems better rewarding than Apollo, HDFC

Deal Cadet Deal Cadet
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Deal Cadet Deal Cadet
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State bank of India General insurance for more details PM can provide quote of all co with discount

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Deal Newbie Deal Newbie
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check ib

Helpful Helpful
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I would recommend TPAs over inhouse teams. There is a reason most companies use TPAs.

Deal Cadet Deal Cadet
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Any specific reason to go with one with TPA

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Deal Cadet Deal Cadet
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cheapest premium

Deal Cadet Deal Cadet
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Can provide maternity cover and pre existing illness cover from 1 st day in Group policy of Minimum 8 people only

Deal Cadet Deal Cadet
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Which group policy are you referring to ?

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Wingman Wingman
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Can we get back the charges of the dialysis in health insurance..I have new india assurance policy… please suggest..

Deal Cadet Deal Cadet
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yes it is covered under day care in future go for cashless instead of Reimbursement

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Deal Cadet Deal Cadet
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SBI GENERAL INSURANCE TOP up paln is best and Cheapest with no copay and with Gauranteed renewal want details PM me

Deal Cadet Deal Cadet
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If I purchase the SBI Top Up policy at 62 years age, the company will not renew my policy once I become 65 years old. Correct?

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Deal Cadet Deal Cadet
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https://cdn0.desidime.com/attachments/photos/615671/original/Screenshot_20200504-224653.png?1588612676Please find premium chart

Deal Cadet Deal Cadet
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https://cdn0.desidime.com/attachments/photos/615672/original/Screenshot_20200504-224944.png?1588612825Pfa upto 10 lakhs

Deal Subedar Deal Subedar
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Thanks for the post. +KG

Specialist Specialist
Moderator
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Imp Point: This benefit is only available for hospitalization in Government AYUSH hospitals or NABH accredited private hospitals. Only few private AYUSH hospitals take NABH.
@drjpatwa
NABH accredition I think is not compulsory now, I myself got reimbursement from a hospital which is only registered
http://pharmabiz.com/NewsDetails.aspx?aid=12045...
https://www.irdai.gov.in/ADMINCMS/cms/frmGuidel...

Beacon Beacon
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Thanks for pointing it out. 1st reference is about newly launched Aarogya Sanjeevani policy as directed by IRDA.

So we have to confirm whether it is applicable to all (old + new other) policy or not. Because policy wording is still same. Either Government / NABH or State approved (Don’t know exact meaning of state approved)

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Deal Cadet Deal Cadet
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Any policy for 70+?

Deal Newbie Deal Newbie
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Any best term insurance plans. My age is 40 years.

Deal Cadet Deal Cadet
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And suggestions for parents aged 58 & 48

Deal Cadet Deal Cadet
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8927 premium 2 adult and two children upto 25 age

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Deal Cadet Deal Cadet
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Nice detailed articles and a lot of pointers, but these PSU insurers are not so bad, they don’t usually reject claims that often and their ICR remaining above 100% consistently.
Can see so many options to choose from, both from public and private providers.

Deal Cadet Deal Cadet
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Vu

Deal Cadet Deal Cadet
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Pm Me for
instant health policy for State bank of india account holders no document required
Cheapest premium is
No sign and no medical test for people upto 65 years with pre existing illness too

Deal Newbie Deal Newbie
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I need info regarding medical reimbursement facility for mh state gov teachers
Please help me

Deal Cadet Deal Cadet
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Deal Cadet Deal Cadet
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