Health Insurance Plans

• Habits: The insurance premiums will be higher for you if you are a daily smoker or consume alcohol on a frequent basis. Insurance companies charge higher premiums for smokers and drinkers to mitigate the risk associated with insuring people who smoke regularly. Regular smokers are more likely to contract diseases such as lung cancer, stroke, heart disease, asthma and respiratory complications.
  
• Pre-existing health conditions: The health insurance premiums for people with pre-existing health issues is higher as the chances of a repeat are high. The insurer covers you against any repeat occurrence of a pre-existing condition.
  
• Profession: Even though it may not seem to be an important factor for health insurance, but your profession matters while buying a policy. Your occupation plays a key role in your overall well-being. Occupational dangers are higher for people working in hazardous industries such as mining, which results in higher insurance premiums for them.

Best health insurance plans come with specific eligibility criteria that individuals must meet to avail of coverage. These criteria vary across insurers and policies but generally include factors such as age, pre-existing conditions, and medical history. Understanding these requirements can help you choose the right policy and avoid claim rejections later.

1. Age of Entry: Most health insurance plans have a minimum and maximum entry age for policyholders. Generally, individual health plans allow entry from 18 years onward, while family floater plans cover children as young as 90 days. Senior citizen health insurance plans usually have a minimum entry age of 60 years, while some policies have an upper age limit of 65 to 80 years. 
   
   
2. Pre-Existing Conditions: Pre-existing conditions, such as diabetes, hypertension, or heart disease, impact eligibility for health insurance. Most insurers have a waiting period ranging from 2 to 4 years before covering pre-existing illnesses, though some policies offer shorter waiting periods with an extra premium. Individuals with severe health conditions may be required to undergo medical tests before approval.

1. Young Professionals and Individuals: Young professionals often overlook health insurance, assuming they are healthy and do not need it. However, buying a health insurance plan early in life offers several benefits, such as lower premiums, access to better coverage, and no waiting periods when they actually need the policy. Additionally, it helps in saving taxes under Section 80D of the Income Tax Act.
   
   
2. Families with Dependents: A family health insurance plan is crucial for those who have dependents, including a spouse, children, or elderly parents. A family floater policy provides coverage for all members under one plan, ensuring medical expenses are covered in case of sudden illness, hospitalisation, or accident.
   
   
3. Senior Citizens and Retired Individuals: Older adults are more prone to health issues, making health insurance a necessity. With rising medical costs, a dedicated senior citizen health insurance plan ensures they receive the best treatment without financial strain.
   
   
4. Self-Employed and Business Owners: Unlike salaried employees who may receive corporate health insurance, self-employed individuals and business owners need to arrange their own coverage. Since they do not have employer-sponsored benefits, an individual or family health insurance plan provides a financial cushion against unexpected medical expenses.
   
   
5. Individuals with Pre-Existing Conditions: People with pre-existing conditions such as diabetes, hypertension, or heart disease should invest in a health insurance policy tailored to their medical needs. While pre-existing conditions typically have waiting periods before coverage begins, purchasing a policy early ensures they are covered when needed. Some insurers offer disease-specific plans that provide better benefits for chronic illnesses.
   
   
6. Employees with Limited or No Corporate Insurance: While many employers offer the best health insurance plan, the coverage may not always be sufficient. Corporate health plans often have limited sum insured amounts, exclusions, and restrictions on family members. Employees should consider purchasing an additional personal health insurance plan to supplement their coverage and avoid out-of-pocket expenses during medical emergencies.

These are two plan options that offer fixed-term coverage. A customer may choose any one of them basis their protection needs.

1. Understand Key Factors Affecting Premiums:

Health insurance premiums depend on several factors, such as age, medical history, sum insured, policy type, and lifestyle habits. Understanding these factors can help you estimate and optimise your premium costs effectively. For instance, your premiums can increase if you have pre-existing conditions or add riders to your plan. 

2. Use an Online Health Insurance Premium Calculator:

An easy way to estimate your health insurance premium is by using an online premium calculator available on insurance company websites. These tools allow you to enter details like your age, number of people covered, sum insured, and any add-ons to get an instant premium quote.

3. Compare Different Health Plans:

Online insurance comparison tools can help evaluate multiple policies, considering factors like claim settlement ratio, hospital network, waiting periods, and customer reviews. A plan with a lower premium may not always be the best choice if it has limitations such as fewer hospitals in its network or longer waiting periods for pre-existing diseases. Comparing plans ensures that you get the best balance between affordability and comprehensive coverage.

4. Optimise Your Premium Costs:

To reduce your health insurance premium, you can opt for a higher deductible. Leading a healthy lifestyle by avoiding smoking, maintaining a good BMI, and exercising regularly can also help lower premiums, as some insurers offer discounts for healthy individuals. Choosing a multi-year policy instead of an annual one may also qualify you for a discount. Lastly, selecting only necessary add-ons ensures that you do not overpay for features that you may not require.

Filing a health insurance claim ensures you receive the financial support needed for medical expenses covered under your policy.

There are two main types of claims you can file, depending on your situation:

1. Reimbursement Claims: In a reimbursement claim, you pay the medical expenses upfront and later submit the bills and necessary documents to the insurance provider for repayment. The insurer verifies the documents before processing the reimbursement.
2. Cashless Claims: In a cashless claim, the insurer directly settles the medical bills with the network hospital. You need to seek treatment at a hospital that has a tie-up with your insurance company and get pre-authorisation for planned procedures.
3. Planned Hospitalisation Process: For planned treatments, inform your insurer and the network hospital in advance. Submit the required documents and obtain pre-authorisation before the hospitalisation to avail of cashless treatment smoothly.
4. Emergency Hospitalisation Process: In emergencies, inform your insurance provider within the stipulated time after admission. If the hospital is part of the insurer’s network, you can opt for cashless treatment; otherwise, you can later file for reimbursement by submitting all necessary documents and medical bills.

Choosing the best health insurance plan requires careful evaluation of various factors to ensure you get the best coverage for your needs.

• Coverage & Sum Insured: Ensure the plan provides adequate coverage for hospitalisation, critical illnesses, pre- and post-hospitalisation expenses, and daycare procedures.
  

• Waiting Period: Check the waiting period for pre-existing diseases and specific treatments to avoid surprises during claims.

• Network Hospitals: A wide network of cashless hospitals ensures you can get treatment without financial stress.
  

• Premium & Affordability: Compare premium costs with benefits to find a plan that fits your budget without compromising on coverage.
  

• Exclusions & Limitations: Read the policy terms carefully to understand what is not covered, such as specific diseases, waiting periods, and sub-limits.
  

• Claim Settlement Process: A smooth and quick claim process ensures hassle-free access to medical benefits when needed.
  

• Additional Benefits & Riders: Look for features like maternity coverage, critical illness riders, and wellness benefits for added protection.

Understanding what your best health insurance policy covers and excludes is essential to avoid surprises during claims. Here is a breakdown of common inclusions and exclusions:

What is Covered?

• Hospitalisation Expenses: Costs related to room rent, ICU charges, doctor’s fees, and nursing expenses.

• Pre- and Post-Hospitalisation: Medical expenses incurred before and after hospitalisation, generally for a specific period (e.g., 30 days before and 60 days after).

• Daycare Procedures: Treatments that don’t require 24-hour hospitalisation, such as cataract surgery or chemotherapy.

• Ambulance Charges: Expenses related to emergency transportation to the hospital.

• Critical Illness Coverage: Lump-sum payment upon diagnosis of specific critical illnesses like cancer, heart attack, or stroke.

• Maternity Benefits: Coverage for delivery expenses and newborn care (depending on the policy).

What is Not Covered?

• Pre-existing Diseases: Medical conditions that exist before buying the policy. They are usually covered after a waiting period.

• Cosmetic Treatments: Procedures done for aesthetic reasons, like plastic surgery, unless medically necessary due to injury.

• Dental and Vision Expenses: Unless specified, most policies don’t cover routine dental or vision care.

• Self-Inflicted Injuries: Injuries caused by intentional self-harm or suicide attempts.

• Alternative Treatments: Unless explicitly mentioned, treatments like naturopathy or acupuncture are usually excluded.

• Non-Medical Expenses: Charges for items like food, toiletries, or administrative fees during hospitalisation.
  

Reading your policy document carefully helps you understand the full extent of coverage and avoid claim rejections later.

When filing a health insurance claim, submitting the correct documents ensures a smooth and hassle-free process. Make sure to submit the following documents within the insurer’s specified timeline to avoid delays or claim rejections.

• Duly Filled Claim Form: A completed and signed form provided by the insurer.

• Health Card Copy: A copy of your insurance card issued by the provider.

• Hospital Discharge Summary: Detailed documentation of your treatment and discharge from the hospital.

• Original Hospital Bills & Receipts: Bills, payment receipts, and invoices for all medical expenses.

• Doctor’s Prescription: A copy of the prescription advising hospitalisation or treatment.

• Investigation Reports: Lab tests, X-rays, MRI reports, or any diagnostic tests conducted during treatment.

• Pharmacy Bills: Original bills and prescriptions for medicines purchased.

• Bank Account Details: A cancelled cheque or bank passbook copy for the reimbursement transfer.

• Valid ID Proof: A copy of a government-issued ID, such as an Aadhaar card or passport.