Buying a health insurance policy in no way guarantees that you will be reimbursed for any surgery or ailment unless you pick up the right insurance policy.

Take the case of Rakesh Kothari, a 41 year- old Kochi based pharmacist. His wife was operated for kidney stones at a hospital in Ernakulam. Despite having a healthcare policy that covered his wife, he was only partially reimbursed by his insurer for all the expenses incurred during the hospital stay.

Hence, it is necessary that one does their homework thoroughly prior to choosing a health insurance policy to avoid any disagreements at the time of reckoning.

One of the biggest mistake people make when it comes to buying a health insurance policy is purchasing it simply based on the price of the policy. The cheapest policy is not necessarily the best one. There is a need to dig deeper and do a thorough check before arriving at a policy that provides the best set of benefits for the premium being charged.

The insurance cover and the benefits of it depend on the premium one would have to pay. The same would differ from one individual to the other. But there are some key features that should be evaluated to ensure that you are buying the best possible policy for yourself.

All healthcare policies have a set of defined exclusions which is basically a set of ailments and conditions that the insurer will not cover. Most policies don’t cover ailments and injuries caused by war, activities like racing, attempted suicide, etc. By comparing multiple policies, you can ensure that the policy you pick doesn’t have a wider set of exclusions than the norm.

Many insurance policies include sub-limits associated with distinct expenses such as surgery, room rent and ICU stay. One policy might dictate that the room rent above one percent of the sum assured per night would not be reimbursed. This would mean that a policy with a sum assured for Rs. 2 lakh would only reimburse room rent up to Rs. 2,000. The policy document needs to be carefully read for sub-limits because the type of room occupied would also end up affecting the total cost of the procedure.

In case your insurance policy has a low sub-limit on rent but you decide to stay in a better-quality room, a huge portion of the cost would fall on your shoulders. Similarly, some policies also have sub-limit for certain surgeries like cataract, hysterectomies and appendicitis. One should be very careful when opting for a health insurance policy solely based on price as these would certainly have sub-limits and restrictions.

Most insurance policies have a waiting period for pre-existing medical conditions or diseases which vary from one another. This ensures that the disease or conditions you have at the time of buying the policy will not be covered by the insurer for a certain defined period of time. Comparing insurance policies will give you an idea of the shortest waiting period. Procedures that don’t need immediate treatment such as cataract and hernia have waiting periods in all insurance policies. A policy with a shorter wait time must be sought out.

Regulation mandates lifelong renewability. Even though renewability of health insurance policies guidelines dictate that the health insurer must renew the policy except on grounds of fraud, moral hazard or misrepresentation, it is nonetheless imperative to scrutinise the terms and conditions of each policy.

It is always better to choose a health insurance company with a wide coverage of hospitals where one can avail of the cashless facility. This is important if you live in a Tier II or III town. Also, check whether important hospitals in the vicinity fall under the purview of your health insurance company.

This states that the policy-holder must pay a specific amount of claim while the balance is borne by the insurance company. Many kinds of policies exist in the market: some are without a co-payment, some have a provision for co-payment above a certain age and some have a co-payment requirement only if treatment is done in a non-network hospital.

This is important as the price of the insurance policy varies based on geographical location where the service is availed. For instance, lower premiums for smaller towns and cities and higher premiums for metros. If the insurance policy is purchased in a small town but treatment is availed in a metro, then the difference might have to be paid by the policy-holder. Many policies with lower premium unpleasantly surprise their clients by requiring them to co-pay.

Many insurance companies offer this feature by hiking the sum insured if a claim hasn’t been made in the previous year. One should choose insurers that offer a higher percentage of no-claim bonus.

It is very important that the insurer has a fast and fair reputation while in settling claims. One should also look at the health claims settlement ratio of the insurer.

Pricing alone should never be the sole criteria for choosing a health policy. It should be compared along with product features and service levels of the company. In addition, policy documents should be downloaded from the internet and thoroughly read and reviewed before arriving at a decision. If this isn’t possible, online web portals that state ratings of healthcare policies must be scoured. Such websites use varied principles to score policies to arrive at a composite score.

• Money Control
• 17/04/2018