Critical Illness Health Insurance Policies

Critical Illness Health Insurance Policies

by | Sep 9, 2023 | Insurance

Healthcare costs are rising exponentially, and the incidence of critical illnesses is on the rise in India. A critical illness health insurance policy is designed to offer financial protection and support when one is diagnosed with a covered critical illness. This report delves into the specifics of critical illness health insurance policies available in India.

                                                                                                                                 Subas Tiwari

Definition of Critical Illness Health Insurance

Critical illness health insurance is a stand-alone policy that provides a lump-sum benefit to the policyholder upon the diagnosis of a covered critical illness. It is distinct from regular health insurance policies, which typically cover hospitalization and medical expenses. Critical illness policies offer a fixed payout to help policyholders meet medical costs, loss of income, or other financial requirements during treatment and recovery.

Key Features of Critical Illness Health Insurance Policies:

  1. List of Covered Critical Illnesses:Critical illness policies specify a list of illnesses covered, which usually includes cancer, heart attack, stroke, kidney failure, major organ transplant, paralysis, and more. The number of covered illnesses may vary among insurers.
  2. Lump-Sum Payout:The policyholder receives a lump-sum amount upon the diagnosis of a covered critical illness, irrespective of the actual medical expenses incurred.
  3. Waiting Period:Most policies have a waiting period from the policy inception during which claims related to pre-existing critical illnesses are not covered. The waiting period varies among insurers.
  4. Survival Period:Some policies require the policyholder to survive a specified number of days (e.g., 30 days) after diagnosis to be eligible for the payout.
  5. Renewable and Convertible Policies:Critical illness policies may be renewable annually, and some insurers offer the option to convert them into a comprehensive health insurance policy without a fresh medical examination.
  6. Tax Benefits: Policyholders can claim tax benefits under Section 80D of the Income Tax Act for premiums paid towards critical illness health insurance.

Coverage and Benefits:

Critical illness policies offer comprehensive coverage for a wide range of critical illnesses. The lump-sum payout can be used for various purposes, such as:

  1. Medical Expenses:It covers the cost of treatment, hospitalization, surgeries, medication, and post-operative care.
  2. Loss of Income:The payout can help cover lost income during the treatment and recovery period.
  3. Debt Repayment:Policyholders can use the payout to repay loans or mortgages.
  4. Lifestyle Changes:The money can be utilized for making necessary lifestyle adjustments due to the illness.

Advantages of Critical Illness Health Insurance Policies

  1. Financial Security:Critical illness policies provide a safety net, ensuring that policyholders and their families are financially secure during challenging times.
  2. No Co-Payment:Unlike regular health insurance policies, critical illness policies generally do not require any co-payment at the time of claim.
  3. Supplement to Existing Coverage:They complement existing health insurance coverage by offering additional protection against critical illnesses.
  4. Flexibility:Policyholders can choose the sum insured based on their requirements and affordability.
  5. Peace of Mind:Having a critical illness policy brings peace of mind, knowing that one is prepared for unforeseen medical emergencies.

Critical Illnesses (Major Inclusions)

  • Cancer
  • Cardiac Arrest
  • Open Chest CABG
  • Replacement/Repair of Heart Valve
  • Coma
  • Kidney Failure Requiring Dialysis
  • Stroke
  • Major Organ Transplant
  • Permanent Paralysis
  • Motor Neuron Disease
  • Multiple Sclerosis
  • Brain Tumour/Meningitis
  • Blindness/Loss of Sight
  • Lung Diseases
  • Liver Failure
  • Myocardial Infraction

The list given above is only indicative & illustrative & not exhaustive.

Limitations of Critical Illness Health Insurance Policies:

  1. Limited Coverage:Critical illness policies cover specific illnesses, leaving out several other health conditions.
  2. Waiting Period:Pre-existing conditions may not be covered during the initial waiting period.
  3. Survival Period:If the policyholder does not survive the specified period after diagnosis, the claim may be denied.
  4. Non-Medical Expenses:The lump-sum payout may not be sufficient to cover all non-medical expenses associated with critical illnesses.

Myths and Facts about Critical Illness health insurance:

Myth 1: Critical Illness Insurance is the same as Health Insurance.

Fact: Critical Illness Insurance and Health Insurance are two different types of insurance. While health insurance covers hospitalization expenses and medical treatments, critical illness insurance provides a lump-sum payment upon the diagnosis of a covered critical illness. The payout from critical illness insurance can be used at the policyholder’s discretion, such as covering non-medical expenses, loss of income, or seeking specialized treatments.

Myth 2: Critical Illness Insurance is unnecessary if you have a healthy lifestyle.

Fact: While a healthy lifestyle can reduce the risk of critical illnesses, it doesn’t guarantee immunity from them. Critical illnesses can affect anyone, regardless of their lifestyle. Critical illness insurance provides financial protection during challenging times, allowing policyholders to focus on their recovery without worrying about financial burdens.

Myth 3: Critical Illness Insurance covers all medical conditions.

Fact: Critical Illness Insurance has a defined list of covered illnesses. The list typically includes major conditions like cancer, heart attack, stroke, organ failure, and more. However, not all medical conditions are covered. It is essential to review the policy documents and understand which illnesses are included and excluded from the coverage.

Myth 4: Only older people need Critical Illness Insurance.

Fact: While the risk of critical illnesses increases with age, young people can also suffer from severe medical conditions. Critical illness insurance can be beneficial for people of all age groups, especially those with family histories of critical illnesses or specific health risk factors.

Myth 5: Critical Illness Insurance is expensive.

Fact: The cost of critical illness insurance varies based on factors like the insured’s age, coverage amount, policy features, and medical history. While it may have higher premiums compared to regular health insurance, the financial protection it offers during a critical illness can outweigh the costs.

Myth 6: Pre-existing conditions are covered under Critical Illness Insurance.

Fact: Most critical illness insurance policies exclude pre-existing conditions for a specific period. If the policyholder is diagnosed with a critical illness related to a pre-existing condition during the waiting period, the claim may be denied. It is crucial to understand the waiting periods and policy exclusions before purchasing the insurance.

Myth 7: Critical Illness Insurance covers all medical expenses.

Fact: Critical illness insurance provides a lump-sum payout upon diagnosis of a covered illness. However, it does not cover all medical expenses. Regular health insurance is designed to cover hospitalization and medical treatment costs, while critical illness insurance offers financial support beyond medical expenses.

Myth 8: Critical Illness Insurance provides immediate coverage.

Fact: Like most insurance policies, critical illness insurance typically has a waiting period before coverage becomes effective. This waiting period can vary depending on the insurer and the policy. It is essential to be aware of the waiting period and understand when coverage starts.

Myth 9: You can purchase Critical Illness Insurance after diagnosis.

Fact: Critical illness insurance is meant to provide protection before the diagnosis of a critical illness. Once you are diagnosed with a covered critical illness, you won’t be eligible to purchase or claim the insurance for that specific condition.

Myth 10: Critical Illness Insurance is a guaranteed payout.

Fact: The policyholder must meet specific criteria and undergo a medical assessment for a successful claim. If the diagnosis does not meet the policy’s definition of a covered critical illness, the claim may be denied.

It’s essential to dispel these myths and have a clear understanding of critical illness insurance before purchasing a policy. Reading and comprehending the policy terms and conditions, coverage details, and exclusions are vital to making an informed decision that best suits your needs. If there are any doubts or questions, it’s wise to seek advice from insurance experts or professionals.

Major exclusions Critical Illness Health Insurance Policies:

  • No illnesses/ailments are covered within the first 90 days of taking the policy cover (inception date of the policy)
  • Pre-existing (health) conditions generally within 48 months
  • HIV/AIDS/STD
  • Congenital defects/anomalies
  • Pregnancy-related complications
  • Drugs & alcohol-related ailments
  • Adventure sports

Here are some tips to consider when purchasing critical illness health insurance:

1. Assess your needs: Evaluate your medical history, family medical history, lifestyle, and the prevalent critical illnesses in your region. This will help you determine the coverage amount and types of illnesses you need to be insured against.

2. Compare plans: Research and compare different insurance providers, their plans, coverage, benefits, and premiums. Look for plans that offer comprehensive coverage for a wide range of critical illnesses.

3. Coverage scope: Check the list of critical illnesses covered under the policy. Common critical illnesses typically covered include cancer, heart attack, stroke, kidney failure, and organ transplants, among others. Make sure the policy covers the illnesses most relevant to your situation.

4. Waiting period: Be aware of the waiting period for specific illnesses. Many critical illness policies have a waiting period before the coverage becomes effective for certain conditions. Opt for a plan with a shorter waiting period if possible.

5. Pre-existing conditions: Understand how the policy treats pre-existing conditions. Some policies may have a longer waiting period or exclude coverage for pre-existing conditions.

6. Sum insured: Choose an adequate sum insured that considers your lifestyle, medical expenses, and potential future healthcare costs. A higher sum insured might result in higher premiums, but it offers better protection.

7. Claim process: Review the claim settlement process of the insurance company. A smooth and efficient claim settlement process is essential during critical times.

8. Exclusions: Carefully read and understand the policy exclusions. Know which situations or illnesses are not covered by the policy to avoid surprises when filing a claim.

9. Renewability and age limit: Check the policy’s renewal provisions and the maximum age until which the policy can be renewed. Opt for a policy with lifelong renewability options if possible.

10. Network hospitals: Confirm the list of network hospitals where cashless treatments are available. Having a wide network of hospitals will be beneficial in emergencies.

11. No-claim bonus: Some policies offer a no-claim bonus, where the sum insured increases if you do not file a claim during a policy year. Consider policies that provide this benefit.

12. Waiting period for claims: In some policies, there might be a waiting period before you can make a claim. Understand this aspect and choose a policy with reasonable waiting periods.

13. Premium affordability: While you shouldn’t compromise on coverage, ensure that the premium is affordable and fits within your budget. It’s essential to pay premiums consistently to keep the policy active.

14. Read reviews and feedback: Look for reviews and feedback from existing policyholders to understand their experiences with the insurance company’s services and claim settlement process.

15. Seek professional advice: If you find the process overwhelming or have specific health concerns, consider seeking advice from a qualified insurance advisor or agent.

Remember that critical illness insurance is not a substitute for comprehensive health insurance. It should complement your regular health insurance coverage to provide additional financial protection against major illnesses. Take your time to research and make an informed decision based on your specific needs and circumstances.

 

Comparison of Critical Illness Policies in the Indian Insurance Market:

  1. Premiums: Premiums vary depending on factors such as age, health condition, sum insured, and the number of critical illnesses covered.
  2. Insurers and Coverage:Different insurance companies offer varying coverage options and additional benefits, making it essential to compare policies.
  3. Claim Settlement Ratio:The claim settlement ratio of insurers is a critical factor to consider while choosing a policy.

Conclusion:

Critical illness health insurance policies in India play a vital role in safeguarding individuals and families against the financial burden of critical illnesses. By offering lump-sum payouts, these policies provide much-needed support during difficult times. However, individuals must carefully assess their needs, compare policies, and select a plan that best aligns with their requirements and budget.

Two-Wheeler Loans: Get on the Road with Financial Flexibility!

Two-Wheeler Loans: Get on the Road with Financial Flexibility!

by | Aug 19, 2023 | Best Buy, Insurance

Two-Wheeler Loans: Get on the Road with Financial Flexibility!

In India, owning a vehicle, whether it’s a car or a two-wheeler, is a common aspiration. However, not everyone has the immediate financial means to purchase a bike outright. Therefore, taking a loan has become the most viable solution. Fortunately, obtaining a bike loan has become increasingly accessible over time. Depending on your credit history, you can secure loans for up to 85 percent of the bike’s cost, and in some cases, even up to 90-95 percent. This facilitates the process of buying a bike, allowing you to repay the loan through affordable EMIs (equated monthly installments). Nevertheless, selecting the most suitable bike loan requires thorough research and careful consideration to meet your specific requirements. 

   Subas Tiwari                      

A two-wheeler loan is a type of loan specifically designed to finance the purchase of a two-wheeler vehicle, such as a motorcycle, scooter, or moped. It is a popular financing option for individuals who want to own a two-wheeler but may not have the immediate funds to purchase one outright.

If you are planning to finance your bike purchase through a bank loan, it is crucial to be aware of the required documents beforehand. Failing to provide the necessary identification and safety-related paperwork can delay the loan approval process, resulting in wasted time. Thus, it is essential to gather all the required documents prior to applying for the loan. Banks typically request different sets of documents from salaried individuals and self-employed individuals to complete the loan approval procedure.

Documents for Two-Wheeler Loans

Every lender requires you to submit certain documents while applying for a loan. Some of the general documents required are given below:

Documents

For Salaried

For Self-employed

Identity Proof

PAN card, voter’s ID, passport, driving license

PAN card, voter’s ID, passport, driving license

Address Proof

Utility bills, passport, etc.

Utility bills, passport, etc.

Income Proof

Salary slips, IT returns, bank statements

Bank statements, IT returns, audited financial statements

Tips for Two-Wheeler Loan

A few loan applicants have had their applications rejected by lenders. This is not a pleasant feeling, and it is not good for your credit score. We have put together a list of tips that can help you apply successfully for a two-wheeler loan. These are as follows:

  • Determine the exact loan amount required:You should assess your needs and calculate exactly how much money you need to buy the bike you want. You should never apply for an amount larger than what you need.
  • Check your eligibility and compare your options:Once you decide how much money you need to borrow, take a look at all the loan options that you are eligible for. This is important. Never apply for a loan you don’t qualify for. This will automatically get your application rejected. Check your eligibility for a two-wheeler loan and make sure you fulfil all the criteria.
  • Check your credit score:Your credit score is one of the most important factors that determine loan approval. Lenders usually reject applications with low credit ratings. So, if your credit history is poor, look at improving it before applying for the loan.
  • Get a guarantor or co-applicant:If your credit score is not up to the requirement of the lender, see if you can get a guarantor or co-applicant. Having a guarantor or co-applicant who has good credit can help you get the loan you want.
  • Fill your loan application properly:Make sure your application is fully filled with all the details your lender requires. An incomplete application or an application that has wrong information may be rejected.
  • Submit all the necessary documents:While submitting your loan application, make sure you submit all the documents the lender requires as well. If you don’t submit the required papers, your application may be rejected.
  • Try applying with your existing lender:If you already have a good existing relationship with a bank, try taking the loan from them. This good standing may help you get a loan even if you don’t fulfil all their criteria.

 

When applying for a two-wheeler loan, there are several important factors to keep in mind to ensure a smooth and successful application process. Here are some key considerations:

 

  1. Creditworthiness:Your credit score and credit history play a significant role in determining your loan eligibility and interest rate. Before applying, check your credit score and address any issues that may negatively impact your creditworthiness.
  2. Loan Amount:Determine the loan amount you need based on the cost of the two-wheeler you intend to purchase. It’s advisable to make a down payment to reduce the loan amount and lower your monthly EMIs.
  3. Research and Compare:Shop around and compare loan offers from different lenders to find the most suitable option. Look for competitive interest rates, favorable loan terms, and minimal processing fees or hidden charges.
  4. Eligibility Criteria:Understand the eligibility requirements of lenders, including factors like age, income, employment stability, and credit history. Ensure that you meet the criteria before applying to increase your chances of approval.
  5. Documentation:Gather all the necessary documents required by the lender, such as identity proof, address proof, income documents, and bank statements. Ensure that your documents are accurate, complete, and up to date.
  6. Loan Repayment Capacity:Assess your financial situation and determine your repayment capacity. Calculate the monthly EMIs you can comfortably afford without straining your finances. Choose a loan tenure that allows you to repay the loan within your financial means.
  7. Loan Terms and Conditions:Read and understand the terms and conditions of the loan agreement thoroughly. Pay attention to details such as interest rates, processing fees, prepayment charges, late payment penalties, and other associated costs.
  8. Additional Charges:Inquire about any additional charges apart from the interest rate and processing fees. These may include documentation charges, insurance charges, and other fees that can increase the overall cost of the loan.
  9. Loan Pre-Approval:Some lenders offer pre-approval for two-wheeler loans. This allows you to know your loan eligibility and approximate loan amount before finalizing the purchase. It can simplify the buying process and provide bargaining power with the dealer.
  10. Loan Repayment Options:Understand the repayment options available, such as online payment facilities, auto-debit, or check payments. Choose the option that is most convenient for you and ensures timely repayment.

Remember to carefully assess your financial situation and borrow responsibly. Consider your monthly budget and ensure that the loan EMIs fit comfortably within your income. By being well-prepared and informed, you can make an informed decision and have a smoother loan application experience.

Do’s and Don’ts for Two-Wheeler Loan

Do’s

Don’ts

Do your research well before you apply

Don’t apply for multiple loans at the same time

Make sure you are eligible for the loan you are applying for

Don’t apply for a loan simply because you get an attractive welcome gift

Compare interest rates and find the best option

Don’t forget to fill in the application form properly

Compare processing fees and other charges

Don’t sign the loan documents without reading them thoroughly

Evaluate your credit score before you apply

Don’t choose an EMI you cannot afford

Submit all the required documents without fail

Don’t forget to pay your EMIs on time

Read the offer document carefully before signing it

Don’t forget to prepay your loan if you can

Easy financing for superbikes

In India, the price of a luxury bike starts from Rs 5 lacs and it can go up to Rs 35 lacs or even more, depending on the model. Easy availability of finance from banks as well as non-banking finance companies for high-end two wheelers prompts customers to take up bike loans.

While 60-65% of the customers buy bikes on loan, some of them may go for a superbike loan only to avoid questions from the tax angle and not because they cannot afford it. But there are also instances of people with a monthly salary of Rs 30,000 buying these bikes.

For banks, offering loans for high-end bikes is one way of getting high net worth individuals (HNI) as customers. Strangely, many banks offer loans for luxury two-wheelers at rates lower than that for standard two wheelers. However, the tenures may be longer due to the high cost of the bike.

In some cases, the bank might not have an off-the-shelf loan product but could tailor one to suit the buyer’s needs. After all, someone who can afford to buy a bike of more than Rs 5 lacs could be a potential high net worth customer for the lender. The loan amounts are usually 70-80 per cent of the bike’s cost, but can also go up to 90 per cent, if the bank is happy with the customer’s profile.

People who buy high-end two wheelers do it more as a status symbol or for pleasure. But those who take loan for standard two wheelers are people who buy them out of necessity, for their daily commute.

The market for high-end bikes in India is at a nascent stage, although it is growing. Harley-Davidson has tie-ups with some private banks. Triumph is the superbike from UK and is financed by a few other private banks under a tie-up. Bucati is also a luxurious bike which is now sold in India. However, only a small percentage of customers opt for such loans.

While a large section of the demand comes from Delhi and Mumbai, cities like Bangalore, Ahmadabad and Chandigarh, too, have been excellent markets as a rich biking-culture already exists there. There is also an increasing demand from the south of India with Kochi, Chennai and Hyderabad where there is scope for a growing market for such superbikes.

Two-Wheeler safety tips for riders in the rainy season

It is very hard to drive on the Indian roads during the monsoon. Drainage, ditches, and speed-breakers are very dangerous during the heavy rains. Here are some safety tips for two-wheeler riders across the Indian cities & towns.

Before starting the vehicle, pre-check your vehicle for clutch, brake, indicators, headlight and fuel.

  • Always wear a fully covered helmet.
  • Follow the traffic rules religiously.
  • Pedestrians are extremely hard to spot in rain, so drive with care.
  • Don’t splash water on pedestrians.
  • Be extra cautious about the stray animals on the road.
  • Use indicators for turns and use head lights (dipper) for overtaking.
  • Avoid using cell phone and listening to music though earphones while driving.
  • Spot the vehicle behind you in the mirror before taking any turn.
  • Do not mix drinking and driving.
  • Drive slowly during the rains as well as on wet roads.
  • Avoid going through the kuchha road.
  • Go slow over the flooded roads.
  • Stay off the roads during heavy rains; park in concrete shade and wait till the rain stops.
  • Ride carefully and keep a safe distance between vehicles.
  • Be sure to wear a raincoat that will keep you dry so that you can wade your way.
  • Do not panic in adverse situations like a traffic jam or signal failure. Keep calm & allow for the traffic woes to ease.
  • Always carry license and other required documents.

Plan the journey in such a way that you reach your destination within daylight hours in rainy season.

The following table helps you compare the interest rates and processing fees offered by leading banks in India:

S.N.

Bank Name

Interest Rate

Processing Fee

1

ICICI Bank 

9.00% p.a. onwards 

Up to 4.75% of the loan amount + GST 

2

IDFC First Bank 

9.99% p.a. onwards 

5% of the loan amount 

3

Axis Bank

11.00% p.a. onwards

2.5% of the loan amount

4

Bank of India 

11.00% p.a. onwards

Contact the bank

5

Punjab National Bank

11.15% p.a. onwards

0.5% of the loan amount subject to Rs.500 to Rs.1,000

6

Canara Bank

11.35% p.a. onwards 

Nil

7

Union Bank of India

12.20% p.a. onwards

Contact the bank

8

Bank of Baroda 

9.40% p.a. onwards

2% of the loan amount 

9

Karnataka Bank 

14.23 p.a. onwards

Contact the bank 

10

HDFC Bank

14.50% p.a. onwards

2.5% of the loan amount

11

State Bank of India

17.75% to 19.50% p.a.

2.00% of the loan amount + GST (minimum of Rs.1,000)

12

UCO Bank 

UCO Float Rate plus 4.80% 

1% of the loan amount (minimum of Rs.500)

13

Indian Overseas Bank 

12.55% p.a. onwards 

Contact the bank 

14

Karur Vysya Bank 

10.80% p.a. to 17.30% p.a. 

1% of the loan amount (minimum of Rs.1,000)

15

Tamilnad Mercantile Bank 

14.95% p.a. 

1% of the loan amount 

Interest rates and processing fees sourced from- https://www.bankbazaar.com as on 06th July 6, 2023

Related

Family Floater Health Insurance Policies

Family Floater Health Insurance Policies

by | Aug 19, 2023 | Best Buy, Insurance

Family Floater Health Insurance Policies

Family floater health insurance policies are a type of health insurance plan that provides coverage for the entire family under a single policy. Rather than individual policies for each family member, a family floater policy offers consolidated coverage for the primary policyholder, their spouse, and dependent children.

The main objective of a family floater policy is to provide financial protection against medical expenses arising from illnesses, injuries, hospitalizations, and other healthcare needs of the family members. It offers a comprehensive and convenient solution to manage the healthcare needs of the entire family under one policy.

Subas Tiwari

Here are some key features and benefits of family floater health insurance policies:

Coverage for the Whole Family: Family floater policies cover all the members of the family, including the policyholder, spouse and dependent children. Some policies may also allow coverage for parents or in-laws.

Sum Insured: The policyholder selects a sum insured, which represents the maximum amount of coverage available for the family members. This sum insured can be utilized by any member of the family as per their healthcare needs.

Premium: The premium for a family floater policy is based on factors such as the age of the eldest member, the sum insured selected, and the overall risk profile of the family. Paying a single premium for the entire family is often more cost-effective than buying separate policies for each member.

Cashless Treatment: Family floater policies usually offer cashless treatment facility wherein the insured members can avail medical treatment at network hospitals without paying cash up front. The insurance company settles the bills directly with the hospital, subject to policy terms and conditions.

Coverage for Hospitalization Expenses: Family floater policies typically cover expenses related to hospitalization, including room charges, doctor’s fees, surgical procedures, medications, and other necessary medical services. The coverage may also include pre and post-hospitalization expenses for a specified period.

Additional Benefits: Family floater policies may offer additional benefits such as coverage for daycare procedures, ambulance charges, maternity benefits, newborn baby care, alternative treatments, preventive healthcare services, and annual health check-ups. These benefits may vary across insurance providers.

Policy Renewal: Family floater policies are generally renewable on an annual basis. Renewing the policy ensures the continuity of coverage for the family.

How is it different from Individual policies?

Individual Policy

Family Floater Policy

Each one of the members have to take a policy for himself/herself.

There is only one policy under whom every member of the family is covered.

 

The sum assured is individually fixed depending on your requirements.

The sum assured on the policy is the same for each member.

 

The claim on the policy will be up to individual limit.

The claim can be on the whole sum assured on the policy or can be claimed by other family members also to that extent.

 

Premium is higher in this case.

 

Premium amount tends to be lower.

Premium is fixed according to the age of the individual.

 

Premium is fixed based on the age of the oldest member.

This policy suits only an individual who does not foresee any increase in family size.

This policy will suit any individual, whose family size is expected to increase either due to marriage/childbirth or in the unfortunate event of a sister becoming a widow or the dependent parents migrate from the native village & stay with the son.

 Is Taking Health Insurance a Must?

While it is not legally required to have health insurance in all countries, having health insurance is generally considered to be a prudent financial decision and can provide several benefits.

Here are some reasons why having health insurance is often recommended:

  • Financial Protection:Health insurance provides financial protection against high medical costs. Medical treatments, hospitalizations, surgeries, and emergency care can be expensive, and having insurance helps mitigate the financial burden by covering a significant portion of these expenses. Without insurance, you may have to pay for medical bills out of pocket, which can be financially devastating, especially in case of major illnesses or accidents.
  • Access to Quality Healthcare:Health insurance gives you access to a network of hospitals, clinics, and healthcare providers. Many insurance plans have tie-ups with specific hospitals or a network of providers, allowing you to receive medical care at discounted rates or through cashless treatment facilities. This ensures that you can receive timely and quality healthcare services when needed.
  • Timely Medical Attention:With health insurance, you are more likely to seek timely medical attention for health concerns, as you have coverage for the associated costs. Regular health check-ups and preventive care can help identify and address health issues early on, increasing the chances of successful treatment and reducing the risk of complications.
  • Coverage for Major Illnesses and Accidents:Health insurance provides coverage for major illnesses and accidents, which can require extensive medical treatments, surgeries, or long-term care. These unexpected events can be financially overwhelming without insurance coverage. Having insurance ensures that you can receive the necessary medical care without worrying about the financial implications.
  • Peace of Mind:Having health insurance brings peace of mind, knowing that you are financially protected against unforeseen medical expenses. It allows you to focus on your health and well-being without the constant worry about how to manage healthcare costs.

However, the decision to take health insurance ultimately depends on your individual circumstances, including your financial situation, access to healthcare, and the healthcare system in your country. It is advisable to carefully assess your needs, compare insurance plans, and consider factors such as coverage, premiums, deductibles, and exclusions before choosing a health insurance policy that best suits your requirements.

Limitations

  • The family floater plans are priced based on the age of the senior most member; as he/she gets older, the flexibility in premium decreases & the cost of the premium increases significantly.
  • The family floater policy will be renewed only till the senior most member reaches the maximum age of the renewability as provided in the policy.
  • Children who reach the maximum age (normally it is 25 years or becomes independent on getting a job or is gainfully self- employed) will have to buy a separate policy for themselves.

IRDAI REVISES GUIDELINES ON STANDARD INSURANCE POLICY- COMMON WORDINGS & ENSURING SEEMLESS PORTABILITY

  • The standard health policy will have benefits of cumulative bonus.
  • Insurers will not be permitted to impose deductibles.
  • Customers will, however, be subject to a fixed co-pay of 5% of claim amount across all ages which will be clearly mentioned in the policy document.
  • All insurers to offer the above cover on indemnity (protection) basis only.
  • There cannot be any other add-on covers like critical illness or benefit-based covers.
  • Insurers will have the final decision on the premium price.
  • These rates would have to be uniform across India.
  • Insurers cannot have geography or zone-based pricing on these rates.
  • The “Arogya Sanjeevani” policy (which is a standardized & custom-built policy model brought out by IRDAI) based on which insurers could bring out their policies & the same can be availed as for both individual lives & family floaters basis on or before 1stApril, 2020
  • The minimum will be Rs.1,00,000 & the maximum will be for Rs.5,00,000.
  • This policy will have no exit age.
  • For this policy, the minimum age required is 18 years & the maximum 65 years.
  • Under the family floater policy, children between 3 months to 25 years would be covered.
  • The standard policy will be offered with a policy term of 1 year.
  • The policy will allow all modes of premium payment, viz., monthly/quarterly, half-yearly & yearly.
  • Treatment for cataract & age-related eye ailments, ulcers, piles, sinus, benign ENT disorders, tonsillitis, adenoidectomy, mastoidectomy & all internal & external tumours will be covered subject to a waiting period of 24 months.
  • Treatment for joint replacement (unless arising from accident & age-related osteoarthritis) will have a waiting period of 48 months.

How is my Family Floater Health Insurance Premium Calculated?

The premium for a family floater health insurance policy is calculated based on several factors. While the specific methodology may vary between insurance companies, here are some common factors that influence the premium calculation:

  • Age of the Oldest Member:The age of the oldest member in the family plays a significant role in determining the premium. Generally, higher age is associated with increased health risks, leading to higher premiums.
  • Sum Insured:The chosen sum insured, which represents the maximum coverage amount under the policy, affects the premium. Higher sum insured amounts typically result in higher premiums.
  • Family Size:The number of family members covered under the policy can impact the premium. A larger family may result in higher premiums compared to a smaller family.
  • Zone or Location:The geographical location of the insured members can influence the premium. Insurance companies may have different premium rates for different regions based on factors like healthcare costs, infrastructure, and demographics.
  • Medical History:The medical history and pre-existing conditions of the insured family members can affect the premium. Certain health conditions may lead to higher premiums or exclusions from coverage.
  • Lifestyle Factors:Lifestyle factors such as smoking, alcohol consumption, or engagement in high-risk activities can impact the premium. These factors may increase the likelihood of health issues and result in higher premiums.
  • Deductibles and Co-payment:If the policy has a deductible or co-payment clause, where the insured has to bear a portion of the expenses, the premium may be adjusted accordingly.
  • Coverage and Add-ons:The extent of coverage and additional benefits chosen, such as maternity coverage, daycare procedures, or alternative treatments, can influence the premium.
  • Claim History:The claims history of the insured members may be taken into account. If there have been frequent or high-value claims in the past, it may result in higher premiums.

It’s important to note that each insurance company may have its own methodology for premium calculation, and the weightage given to each factor may vary. It’s recommended to reach out to insurance providers or agents for accurate premium quotes based on your specific family’s details and requirements.

Here are 20 tips to consider when buying a family floater health insurance policy:

  1. Assess Your Family’s Healthcare Needs:Understand your family’s medical history, current health conditions, and anticipated healthcare needs to determine the appropriate coverage required.
  2. Evaluate Insurer Reputation:Research and choose a reputable insurance company with a strong track record in providing quality coverage and prompt claim settlements.
  3. Coverage Adequacy:Ensure the policy offers sufficient coverage to meet potential medical expenses for the entire family.
  4. Network Hospitals:Check the list of network hospitals affiliated with the insurance provider to ensure convenient access to quality healthcare services.
  5. Pre-Existing Conditions:Review the policy’s stance on pre-existing conditions and understand if there are any waiting periods associated with coverage for such conditions.
  6. Policy Exclusions:Thoroughly read and understand the policy exclusions to know what conditions, treatments, or situations are not covered.
  7. Room Rent Limit:Check the sub-limit on room rent and make sure it aligns with the cost of hospitals in your preferred location.
  8. Co-payment:Understand if the policy has any co-payment requirements, where you need to bear a percentage of the medical expenses.
  9. No Claim Bonus:Inquire about the availability of a no claim bonus, which rewards policyholders with increased coverage or reduced premiums for claim-free years.
  10. Claim Settlement Ratio:Research the insurer’s claim settlement ratio to assess their efficiency in processing and settling claims.
  11. Waiting Periods:Understand the waiting periods associated with specific treatments, maternity benefits, and other coverage aspects.
  12. Daycare Procedures:Check if the policy covers daycare procedures that do not require 24-hour hospitalization.
  13. Maternity Benefits: If you anticipate having children, evaluate the coverage for maternity expenses, including pre and post-natal care, delivery charges, and newborn baby care.
  14. Policy Renewal Age:Check the maximum age up to which the policy can be renewed to ensure long-term coverage for your family.
  15. Premium Affordability: Compare premium costs across insurers and assess the affordability of the policy in relation to your budget.
  16. Claim Process:Understand the claim filing process and the ease of claim settlement, including the availability of cashless treatment facilities.
  17. Additional Benefits:Consider any additional benefits offered by the policy, such as coverage for alternative treatments, preventive healthcare services, or annual health check-ups.
  18. Customer Service:Evaluate the insurer’s customer service track record, including responsiveness, support, and grievance resolution.
  19. Policy Flexibility: Assess if the policy allows for adding or removing family members during the policy period, considering potential changes in family structure.
  20. Read Policy Documents:Thoroughly read and understand the policy documents, including terms, conditions, and limitations, before making a final decision.

It’s advisable to consult with financial advisors who can provide personalized guidance based on your specific requirements and preferences.

Related

Family Floater Health Insurance Policies

Health Insurance Policy for Senior Citizens

by | Jul 15, 2023 | Best Buy, Insurance

Health Insurance Policy for Senior Citizens

Over the past few years, there has been a growing awareness among individuals regarding health insurance. Furthermore, following the Covid-19 pandemic, there has been a significant surge in the number of people purchasing health insurance. It is now imperative for everyone to obtain a health insurance policy that covers their entire family. Particularly, if there are elderly parents residing in your household, the importance of obtaining health insurance becomes even more pronounced. This is primarily due to the elevated risk of various ailments associated with old age. By having health insurance, one can avoid incurring substantial hospital expenses during the treatment of such illnesses.

                                                                                                                                                         Subas Tiwari                                                                                                                                                                            Before purchasing a health insurance policy for your elderly parents, it is crucial to familiarize yourself with certain aspects of health insurance. This understanding will enable you to address any issues that may arise when dealing with Senior Citizen Health Insurance.

Why analyze Health Insurance Policy for Senior Citizens?

Senior citizens must get health cover to evade health problems and avoid financial shock. Many aged individuals are worried about the spiraling cost of healthcare and what havoc it could do to their financial security. With medical inflation growing at 15% per year, the cost of procedures like angiography and gall bladder removal has increased tremendously, a report released by KPMG and Assocham noted. Around 38% of the elderly respondents to the survey in India ranked health and financial insecurity among key fears. Low insurance penetration in India means many senior citizens lack the resources to fund treatment.

GROUP INSURANCE-Employer’s Coverage

The need for a health insurance cover is all the more necessary for those who enjoyed the health cover under the ‘Group Insurance Scheme’ floated by the insurance companies under a tie-up with their organization (both government-owned & private sector companies). Till their retirement, the employees/officers were covered under this Scheme, but the cover ceases abruptly immediately after their superannuation. Then the employee gets the ‘senior citizen’ tag & with it comes the financial limitation to live off his pensionary benefits & the sudden ‘disappearance’  of his health cover causing him anxiety.

We have also come across many instances of serving employees not bothering to take any sort of health cover during their service years especially in the un-organized sector & under the self-employed category.

Senior Citizen Health Insurance- a necessity?

Senior citizen health insurance is a necessity especially when you are planning to retire or already retired and carry on life on pension or interest income from savings. A sudden medical emergency can result in a financial crisis other than health setbacks. To avoid this, it is prudent to take a comprehensive senior citizen medi-claim policy.

According to the guidelines by IRDA, every health insurance provider has to mandatorily offer health coverage to individuals’ up to 65 years of age. However, most of the Health insurance Companies are offering health cover to senior citizens aged more than 65 years of age & even up to their platinum years. These guidelines will not only help individuals get coverage at later stages of their life but will also allow them to shift insurers (portability) in case they are not satisfied with their current health insurance provider.

Consumer VOICE readers might be aware that Consumer Voice had carried out a story on the same subject in May 2014. We at the BFSI Desk of CV wanted an updated information as there have been subtle changes brought out by the Health Insurance Companies under the regulatory control of IRDAI. Hence this story in the current issue.

Sum Insured (Health Insurance cover)

Based on the financial capacity/affordability of the insured, we have opted for a Rs.3, 00,000 health insurance policy, as market indices indicate that an average man/woman above 60 years of age would be able to meet his medical treatment (excluding major lifelong diseases) within this amount, if he does not suffer from any serious medical complication at the time of taking a health insurance policy.

Major inclusions in a Senior Citizens Health Insurance Policy

  • In-patient Treatment

Covers medical expenses for Hospitalization due to an illness or accident.

  • Hospitalization Cover

 Expenses incurred as a patient after admission of more than 24 hrs. The expenses include room charges, doctor fees, minor surgery cost, cost of medicine and drugs, etc.

  • Day care

Expenses which arise from use of special equipments or procedures like chemotherapy, dialysis, etc.

  • Pre and post of hospitalization

Medical expenses for pre and post of hospitalization; but the number of days it is made available before/after hospitalization will vary across insurers.

  • Domiciliary Treatment

The medical expenses incurred by an insured for availing medical treatment at his/her home which would otherwise have required hospitalization (non-admission due to non-availability of beds or that the patient cannot be moved due to his poor medical condition duly certified by the Hospital).

  • Organ Donation

These are medical expenses on harvesting the organ from the donor at the time of such organ transplants, but do not cover the cost of the organ itself.

  • Co-Payment

This term means that this is a cost-sharing requirement where the policyholder/insured will bear a specified percentage of the admissible claim amount. However, this does not reduce the sum insured. It’s a kind of margin money the patient brings in while getting admitted for cashless treatment. This is often resorted to by health insurance companies as the cost of treatment for senior citizens could be high & this clause ensures that at least a part of the cost is picked up by the insured.

Tax Benefits to Senior Citizens on Health Insurance

A senior citizen health policy covers medical expenses as well as helps you to get tax exemption under section 80D of the Income Tax Act, 1961. You are eligible for an income tax rebate of up to Rs 50,000 if you hold a mediclaim policy for senior citizens for your elderly parents.

An additional tax rebate of Rs 5,000 can be earned on payments made towards preventive health check-ups every financial year. Additionally, you can also get a rebate of up to Rs 1 lakh if the senior citizen undertakes a critical disease treatment.

In case you are an earning senior citizen and are also paying the health insurance premium on behalf of your son or daughter, then you can avail an additional income tax rebate of Rs 25,000. This means that you can avail tax deduction of up to Rs 75,000 in a financial year under section 80D.

Major exclusions in the Policy

  • Cosmetic surgery
  • Dental Treatment
  • Aesthetic treatment
  • Plastic Surgery
  • Weight Reduction procedures
  • AIDS/ Sexually Transmitted Diseases (STD)
  • Stem Cell Procedures
  • Robotic Surgery

Difficult terminologies explained

  • Restoration of Sum Assured

In case of hospitalization, once your claim for a particular disease/ailment is fully exhausted, then you can invoke this basic cover for any other ailment within the same policy period

  • Day Care Cover

They are important for the consumer as it reduces his cost or covers additional medical expenses but is not going to alter his options in a major way while the senior citizen chooses a policy.

  • Domiciliary treatment

These are the expenses incurred in case patient is being treated at home due to non-availability of beds in hospital or if the patient is not in a medical condition to be moved to a hospital.

What Senior Citizens look for in a Policy to make it attractive to them?

  • To make it an attractive buy, the health insurance companies can tinker with the Pre Existing Disease waiting periodto 1 year minimum, as at their age, it is foolish to expect a very robust health profile & most of them would be carrying some ailment or the other on them, which would be as a result of the age factor & the nature’s way of decay.
  • Out Patient treatment(OPD) of ailments not categorized as lifelong diseases  and also not requiring hospitalization could be included as one of the basic covers or add-on covers with additional premium.

Keep these things in mind while buying a Health Insurance for Senior Citizens

  • Day Care Facilities-Due to technological advancement in medicine, a lot of medical procedures and surgeries can be done through day care treatments. But under a standard health insurance policy, a senior citizen must be hospitalized for at least 24 hours to raise a claim. Hence, it is better to buy a senior citizen plan that covers a variety of day care procedures like dialysis, chemotherapy, radiotherapy, etc.
  • Network Hospitals-Every health insurance company has an extensive network of hospitals where you can avail cashless hospitalization facilities. Enquire about the list of network hospitals of your insurance company before buying a plan. This will help you to know if a good hospital in your locality is on the list.
  • Process Of Health Insurance Claim Settlement-Claim settlement ratio and the time taken by an insurance company to settle claims should also be taken into consideration while purchasing a senior citizen health policy. If an insurance company’s claim settlement time is less and the claim settlement ratio is high, it means that the chances of your claim getting settled quickly are more.
  • No Claim Bonus-A no claim bonus discount is provided by most insurance companies if no claims are lodged by the policyholder in the previous year. In such a case, either the policy premium decreases or the sum insured amount increases.
  • Free Medical Health Check-Up Facility-The most suitable health insurance plans for senior citizens is the one which allows the policyholders to avail medical check-up for free on an annual basis. This usually is offered after the completion of certain policy years or after every two/three claim-free years.
  • Renewal Process-The best health insurance plan offers a lifetime renewability option so that you won’t have to buy another health plan in your old age. A policy that cannot be renews, especially after 60 years, is not the right plan for a senior citizen.
  • Waiting Period for Pre-Existing Diseases-Most elderly people suffer from pre-existing diseases whose treatment are expensive. Hence, it is ideal to opt for a senior citizen health insurance plan that comes with a minimum waiting period for pre-existing diseases.

Domiciliary Hospitalization- In case of unfortunate situations, an elderly person’s health condition may not allow him/her to get admitted to a hospital. In such a case, health plans with domiciliary hospitalization cover will take care for home treatment expenses as long as it has been advised by a qualified doctor.

IMPORTANT HANDLES OF THIS STORY

  • Go in for minimum waiting period for PED
  • Go for minimum co-payment
  • Go for top-up policy within the same insurance policy or a different insurer for lifestyle diseases

The following table shows the various senior citizens health insurance plans that you can buy

Senior Citizens Health Insurance Plans Entry Age Sum Insured (Rs) Pre-existing Disease Coverage Co-Payment Pre-Policy Medical Check-up
Aditya Birla Activ Care Plan 55-80 years Standard: 3 lakh to 10 lakh
Classic: 3 lakh to 10 lakh
Premier: 5 lakh to 25 lakh		 From the 3rd year 10% under the Premier plan
20% under the Standard and Classic plan		 Required
Bajaj Allianz Silver Health Plan 46-80 years Plan A: 50,000 to 5 lakh
Plan B: 3 lakh to 10 lakh		 From the 2nd year 10% on all claims under Plan B
20% on all treatments in a non-network hospital under Plan A		 Required
Care Senior Health Advantage Plan 60 years onwards 5 lakh, 10 lakh From the 3rd year 50% on all claims up to 70 years
60% on all claims above 70 years		 Not required
Cholamandalam Flexi Health Supreme Plan 18-75 years Basic: 5 lakh to 25 lakh
Plus: 5 lakh to 25 lakh
Premiere: 30 lakh to 5 crore		 From 3rd/4th year (depending on the plan variant) NA NA
Digit Health Insurance Plan 18 years onwards 2 lakh to 3 crore From 2nd/4th year (depending on the plan) 20% if treatment is taken at a non-network hospital May be required
Future Generali Varishta Bima 60 years onwards 2 lakh to 10 lakh From the 2nd year 50% on PED claims and 25% on all other claims Required for sum insured of Rs 7.5 lakh & Rs 10 lakh
IFFCO Tokio Individual Health Protector Plan 18-65 years 50,000 to 20 lakh From the 4th year NA Required for people above 45 years
Kotak Mahindra Health Premier Plan 18-65 years Standard: 2 lakh
Advantage: 3 lakh to 10 lakh
Edge: 5 lakh to 20 lakh
Elite: 10 lakh to 25 lakh
Absolute: 25 lakh to 2 crore
360: 2 lakh to 2 crore
Total: 2 lakh to 2 crore		 From the 4th/5th year (depending on the plan variant) 10% or 20% for treatment in a higher zone (depending on the zone) Required for people above 55 years and/or sum insured of Rs 50 lakh & above
Liberty HealthPrime Connect Plan 18-65 years Essential: 10 lakh to 50 lakh
Optimum: 10 lakh to 50 lakh
Optimum Plus: 75 lakh, 1 crore		 From the 4th/ 5th year (depending on the plan variant) No co-pay Required for people above 35 years and/or sum insured of Rs 30 lakh & above
Magma HDI OneHealth Senior Plan 56 years onwards Gold: 3 lakh to 25 lakh
Platinum: 3 lakh to 25 lakh		 From the 2nd year 30% on all non-accidental claims May be required
ManipalCigna Prime Senior Plan 56-75 years Classic: 3 lakh to 50 lakh
Elite: 5 lakh to 50 lakh		 From the 3rd year 20% Not required
National Senior Citizen Mediclaim Policy 50-80 years Plan A: 1 lakh to 10 lakh
Plan B: 1 lakh to 10 lakh		 From the 3rd year 10% on PED diabetes/hypertension claims and 25% on both PED claims Required
New India Senior Citizen Mediclaim Policy 60-80 years 1 lakh, 1.5 lakh After 1.5 years 10% Required
Niva Bupa (Formerly known as Max Bupa) Senior First Plan 61-75 years Gold: 5 lakh, 10 lakh
Platinum: 5 lakh to 25 lakh		 From the 3rd year No co-pay Not required
Oriental HOPE Insurance Plan 60 years onwards 1 lakh to 5 lakh From the 3rd year 20% Required
Raheja QuBE Health Insurance Plan 18-65 years Basic: 1 lakh to 50 lakh
Comprehensive: 3 lakh to 50 lakh
Super Saver: 1 lakh to 50 lakh
Ala Carte: 1 lakh to 50 lakh		 From the 5th year 20% for people above 60 years (except under the Super Saver plan) Required for people above 55 years and/or sum insured of Rs 10 lakh & above
Reliance Health Gain Plan 18-65 years
(No age limit for sum insured of Rs 3 lakh)		 Plus: 3 lakh, 5 lakh
Power: 10 lakh to 20 lakh
Prime: 25 lakh to 1 crore		 From the 4th year 20% for people above 60 years May be required
Royal Sundaram Lifeline Health Insurance Plan 18 years onwards Classic: 2 lakh to 4 lakh
Supreme: 5 lakh to 1 crore
Elite: 25 lakh to 1.5 crore		 From the 3rd/ 4th/ 5th year (depending on the plan variant) 20% on all claims of international treatment for critical illness NA
SBI Super Health Insurance Plan 18 years onwards Elite: 3 lakh to 25 lakh
Premier: 3 lakh to 10 lakh
Platinum: 10 lakh to 50 lakh
Platinum Infinite: 50 lakh to 2 crore		 From the 3rd year 20% on all OPD professional fee claims
30% on all OPD diagnostic & pharmacy claims
50% on OPD Dental/Vision cover		 Required
Star Senior Citizen Red Carpet Health Insurance Plan 60-75 years 1 lakh to 25 lakh From the 2nd year 30% on all claims Not required
Tata AIG MediCare Premier Plan 18-65 years 5 lakh to 3 crore From the 3rd year NA Required for people above 55 years and/or sum insured of Rs 50 lakh & above
United India Senior Citizen Health Insurance Plan 61-80 years 1 lakh to 3 lakh From the 5th year 20% on pre-post hospitalization claims Required
Universal Sompo Senior Citizen Health Insurance Plan 60-70 years 1 lakh to 5 lakh From the 3rd year 10% on all hospitalization claims
15% on day care claims
20% on PED claims		 Required
Zuno (Formerly Edelweiss) Health Insurance Plan 18-65 years
(No age limit for the Platinum plan)		 Silver: 1 lakh to 5 lakh
Gold: 5 lakh to 20 lakh
Platinum: 15 lakh to 1 crore		 From the 3rd/ 4th/ 5th year (depending on the plan variant) 20% for people above 60 years Required for people above 50 years

Product Info sourced from Policybazaar

 

Related

Critical Illness Health Insurance Policies

Tips to Increase the Chances of Avoiding Health Insurance Claims Rejection

by | Jul 8, 2023 | Best Buy, Insurance

Tips to Increase the Chances of Avoiding Health Insurance Claims Rejection

Health insurance proves invaluable during challenging situations such as medical emergencies. It not only provides financial relief by covering the substantial expenses associated with major diseases but also offers peace of mind. However, this assurance is only realized when you, as the insured, receive the complete claim amount from your health insurance company.

Nevertheless, there are instances when insurance companies deny claims, leaving you responsible for the entire treatment cost. In order to prevent claim rejection by the insurance company, it is crucial to avoid making these mistakes.

  Subas Tiwari

Here are 20 potential reasons why health insurance claims could be rejected

  1. Ineligible or expired coverage:Your policy may have lapsed or you may be attempting to claim for services not covered by your policy.
  2. Non-covered services:The treatment, procedure, or medication you’re claiming for may not be included in your policy coverage.
  3. Lack of pre-authorization:Some insurance plans require prior approval for certain procedures, tests, or surgeries, and failure to obtain it can lead to claim rejection.
  4. Incorrect or incomplete information:Providing inaccurate or incomplete details on the claim form, such as personal information, policy number, or medical codes, can result in rejection.
  5. Filing deadline missed:Insurance companies often have specific timeframes within which claims must be submitted, and missing the deadline can lead to rejection.
  6. Duplicate claims:Submitting multiple claims for the same service or treatment can result in rejection unless explicitly instructed by your insurance provider.
  7. Coordination of benefits:If you have multiple insurance policies, failure to coordinate them properly may result in claim denials.
  8. Out-of-network providers:Seeking medical care from providers outside your insurance plan’s network can lead to claim rejection or higher out-of-pocket costs.
  9. Experimental or investigational treatments:Coverage limitations may exist for experimental or investigational treatments that have not been approved by the insurance provider.
  10. Billing errors:Mistakes in billing, coding, or documentation by healthcare providers can lead to claim rejections.
  11. Medical necessity not met:If the insurance company determines that a treatment or procedure was not medically necessary, the claim may be rejected.
  12. Incorrect or mismatched diagnosis and procedure codes:If the diagnosis and procedure codes reported on the claim form do not align or are incorrect, it can result in claim denial.
  13. Lack of documentation:Insufficient or incomplete medical records or supporting documentation for the claimed services can lead to rejection.
  14. Coverage waiting periods:Some insurance policies have waiting periods for specific services or conditions. If you file a claim during a waiting period, it may be rejected.
  15. Policy exclusions:Certain conditions or treatments may be explicitly excluded from coverage under your policy, resulting in claim denials.
  16. Late premium payments:If you fail to pay your insurance premiums on time, your coverage may be suspended or terminated, leading to claim rejection.
  17. Intentional misrepresentation:Providing false or misleading information when applying for insurance or filing a claim can result in claim rejection.
  18. Non-compliance with treatment protocols:If you deviate from the prescribed treatment plan or fail to follow recommended protocols, the insurance company may reject your claim.
  19. Pre-existing conditions:Some policies have waiting periods or exclusions for pre-existing conditions, which can result in claim rejections related to those conditions.
  20. Policy limitations:Your policy may have specific limits on the number of visits, services, or amounts covered, and exceeding those limits can lead to claim denials.

Please note that these reasons may vary depending on your specific insurance policy and provider. It’s important to review your policy documents and contact your insurance provider for accurate information about claim rejection reasons.

To expedite the process of getting health insurance claims in India, consider the following tips:

  1. Understand the claim process:Familiarize yourself with the claim filing process outlined by your insurance provider. Understand the required documents, claim forms, and procedures to streamline the process.
  2. Keep documentation ready:Maintain an organized record of all necessary documents required for claim submission, such as medical bills, prescriptions, diagnostic reports, discharge summaries, and any other supporting documents.
  3. Submit claims promptly:File your insurance claims as soon as possible after receiving medical treatment. Delaying claim submission can prolong the processing time.
  4. Complete and accurate information:Ensure that all claim forms are filled out accurately and completely, providing the necessary information, policy details, diagnosis codes, and treatment details. Any errors or missing information can cause delays in processing.
  5. Submit electronic claims:If your insurance provider allows electronic claim submission, opt for this method. Electronic claims are generally processed faster than paper claims.
  6. Follow up promptly:Regularly follow up with your insurance provider to inquire about the status of your claim. Stay informed about any additional documentation or requirements that may be needed.
  7. Maintain open communication:Stay in touch with your insurance company’s customer service representatives and claims department. Promptly respond to any requests for information or clarification to expedite the process.
  8. Utilize online portals:Many insurance providers offer online portals or mobile apps for claim submission and tracking. Utilize these platforms for convenience and faster processing.
  9. Seek pre-authorization when required:For planned procedures or treatments that require pre-authorization, obtain the necessary approvals from your insurance provider before proceeding. This helps ensure smooth claim processing later.
  10. Opt for cashless claims:If your insurance policy offers cashless facility, choose network hospitals where you can avail cashless treatment. This eliminates the need for reimbursement claims and speeds up the process.
  11. Maintain regular premium payments:Ensure that your insurance premiums are paid regularly and on time. Non-payment can lead to claim rejection or delays.
  12. Utilize technology:Take advantage of digital tools and services offered by your insurance provider, such as online claim tracking, e-mail communications, or mobile apps, to expedite the claim process.
  13. Provide additional information if requested:If your insurance provider requests additional documents or information to process your claim, provide them promptly to avoid delays.
  14. Be persistent but polite:In case of delays or issues with claim processing, remain persistent in following up with your insurance provider. However, maintain a polite and cooperative demeanor to facilitate a smooth resolution.
  15. Seek professional assistance if needed:If you encounter significant delays or challenges in getting your claim processed, consider seeking help from a professional insurance advisor or broker who can provide guidance and escalate the matter if necessary.

Remember that claim processing times can vary depending on various factors, including the complexity of the claim, documentation provided, and the efficiency of the insurance provider’s processes. By following these tips and maintaining proactive communication, you can increase the chances of receiving your health insurance claims faster.

If you have a complaint related to health insurance in India, you can follow the below process to escalate and seek resolution:

  1. Contact the Insurance Company:Start by contacting your health insurance company’s customer service department. Explain your complaint and provide details of the issue you are facing. You can reach out to them through their dedicated customer care helpline, email, or online complaint portals.
  2. Maintain Written Documentation:Keep a record of all communication with the insurance company. Maintain copies of emails, letters, or any other form of correspondence exchanged during the complaint resolution process. This documentation will be useful if you need to escalate the complaint further.
  3. Escalate to the Grievance Redressal Officer:If your complaint is not resolved satisfactorily by the customer service department, escalate it to the insurance company’s Grievance Redressal Officer (GRO). The contact details of the GRO are usually mentioned on the insurance company’s website or policy documents. Submit a written complaint to the GRO, clearly explaining the issue and attaching relevant supporting documents.
  4. Await Resolution:Once you have lodged the complaint with the GRO, the insurance company is expected to investigate and resolve the issue within a specific timeframe, usually within 15 days. During this period, the insurance company may request additional information or documents for their investigation. Maintain regular communication with the insurance company to track the progress of your complaint.
  5. Approach the Insurance Ombudsman:If your complaint remains unresolved or you are not satisfied with the resolution provided by the insurance company, you can approach the Insurance Ombudsman. The Insurance Ombudsman is an independent authority appointed by the Insurance Regulatory and Development Authority of India (IRDAI) to address grievances related to insurance. File a complaint with the Ombudsman providing all relevant details, including the complaint history, correspondence, and supporting documents. The Ombudsman will review the case and provide a resolution within the framework of the IRDAI guidelines.
  6. Seek Assistance from IRDAI:If you are not satisfied with the resolution provided by the Insurance Ombudsman, you can escalate the matter to the Insurance Regulatory and Development Authority of India (IRDAI). The IRDAI has a Grievance Redressal Cell to handle complaints against insurance companies. File a complaint with the IRDAI Grievance Redressal Cell, providing all necessary details and supporting documents. The IRDAI will investigate the matter and provide a resolution based on their findings.

It’s important to note that the specific process and contact details for filing complaints may vary depending on the insurance company. It is advisable to refer to the policy document or visit the insurance company’s website for the exact procedure to lodge a complaint.

Related

Recurrent pregnancy loss

Recurrent pregnancy loss

With an increasing number of affected couples, recurrent pregnancy loss (RPL) has become a widespread reproductive health problem. Clinically, it is...

read more

Personal Accident Insurance

by | Jun 10, 2023 | Insurance

Personal Accident Insurance

During these times when people have to adhere to strict timelines, work longer hours, attend tours and meetings, the working class is always on the go. To minimize the risks associated with mobility, it is essential for individuals to obtain Accident Insurance coverage for themselves and their families.

                                                                                                                                    Subas Tiwari

Is Personal Accident Cover so important?

Indeed, in the era of globalization and the continuous mobility of the workforce, which includes self-employed individuals, businessmen, and traders, it is crucial to prioritize securing sufficient insurance coverage for oneself and their family members, including dependent parents or in-laws. This ensures that in unforeseen situations, there is no reliance on bank loans or borrowing from friends or relatives to cover medical expenses. By having adequate insurance, individuals can swiftly access necessary treatments and return to work promptly.

So, before we embark upon the task of finding out a suitable accident policy for individuals, let us find out why it is a must to be covered for accident insurance & what are the benefits/riders & common exclusions?

What is Personal Accident Insurance?

Personal accident insurance covers injuries or death that has been caused due to an accident. This is one of the most affordable and limited form of life & health insurance policy that is mostly availed by people who are travelling frequently by road, water or airways.

Why is it called Personal Accident Insurance?

There are accident insurance policies for Group Cover taken by organizations for their employees’ benefit (Group Accident Insurance) & there are those where the Corporate-employer takes accident insurance cover for their employees called Corporate Accident Insurance. So the term’ personal” denotes ‘individual’ accident insurance policies (where family floater options are also available).

Why do you need to have one?

Personal accident insurances cover the policyholder against death or disability due to an accident. All general insurance companies offer these policies. Firstly, it will provide financial support to the policyholder if he is disabled after an accident. Secondly, the magnitude of the mishap doesn’t matter; even minor ones like falling off a bicycle and breaking an arm, or fracturing a leg while playing football are covered by the policy.

PSU insurers offer cheap personal accident covers while private insurance companies offer a wider range of benefits, but the premium rates are higher. You can take a cover of up to 8 times your annual salary. Apart from the basic death and permanent disability cover, you can buy additional protection against partial and temporary disability, even loss of livelihood.

It’s important to understand the terms and conditions clearly before you buy a policy. For example, hospitalization benefit can be availed of only if the policyholder is admitted within seven days of the accident and is hospitalized for at least 24 hours.

How does it work?

One has to pay a monthly, quarterly or yearly premium that remains the same till the entire policy coverage period. A cash benefit can be availed as reimbursement when the policy holder has got a major accidental injury. Compensation is provided if the insured person dies due to accident. The coverage is generally valid even when you are out of the country. No medical check-ups are required prior to availing the personal accident insurance policy. It is important to pay the premium in time so that you can enjoy the benefits of this policy. You can also add your family members under this policy.

What is covered?

Accidental death– On the event of death due to accident, the policy holder’s family (or nominee) gets accidental death compensation of Sum Insured Value just before death (usually 100%+ no claim bonus). Some insurance policies also provide for reimbursement by way of payment of lump sum on education expenses of 2 kids under the Education Fund.

Accidental permanent disability– It means the policy holder has lost one or more limbs due to an accident or one or more parts of his/her body has been dismembered. The insured person is liable to get a certain amount as reimbursement of treatment cost (usually 100% to 125% of Sum Insured).

Accidental permanent partial disability- It means loss of one index/thumb finger or one ear or loss of vision in one eye or loss of one hand/arm/leg, which is a partial damage of permanent nature which is irreversible. Here the compensation is a calculated percentage of Sum Insured.

Accidental temporary disability– It means the policy holder has got severe injuries which have made him/her temporarily disabled/physically disadvantaged (physically challenged). In this case, he/she is entitled to get a lump sum compensation for the number of days where he/she is not able to work.

Medical reimbursement for health complications that has arisen from the accident– Many personal accident policies also provide reimbursement for medical complications that has  arisen due to an accident, like treatment of mental trauma (cost of medicines or cost of psychiatric counselling sessions), and so on.

What are not covered? (EXCLUSIONS)

The following could be the most common exclusions (not covered) in the Personal Accident Insurance Policy Cover. Take adequate care to read them, understand the implications & take an informed decision to buy.

  • Suicide
  • Self-inflicted injuries
  • Influenced by liquor and drugs
  • Any pre-existing conditions or infirmity
  • Hazardous sports or careers (such as deep sea diving, working in mines, circus; in Army, Air Force or Navy, Airplane Pilots, etc)
  • Use of alternate systems of medical treatments (such as AYUSH)
  • War situations, mental disorders and pregnancy/childbirth

(These are only illustrative & not exhaustive)

Comparison of Accident Insurance Vis-à-vis Health Insurance and Term Plan Insurance 

Personal Accident Insurance Health Insurance Term Plan Insurance
Sum assured is payable against injuries/disabilities/death/other related expenses caused by accident, subject to exclusions & individual limits  Sum is available for hospitalization expenses only during the life of the insured Sum assured is payable on death of the insured only
Chances of meeting with an accident is higher in today’s times Chances of getting hospitalized for diseases are comparatively slimmer Chances of death of the assured are much slimmer if either/both policies are taken
Premium amount is cheaper compared to other policies Premium is higher of these two policies Sum assured is huge & taking this into account, premium is reasonable
Premium is fixed on the basis of nature of job and/or working conditions (not based on age of the insured ) Premium is fixed on the basis of age, health history, lifestyle, etc

Premium is fixed on the age &

nature of job and/or working conditions, health history, lifestyle, etc

Additional Benefits (Covers) Built into the Policy (FREE –NO COST TO PREMIUM)

There is no standardized format in the policies to look for. The offering in the product of Accident Insurance Policy of an Insurance Company varies from that of another. However, we shall look into some of the additional benefits of which some of them could be offered to the policy-seeker, and which could be built-into the policy.

  • Education grant to children (limited to 2 children)
  • Transportation expenses of mortal remains subject to cap
  • Travel expenses of 1 relative subject to cap
  • Purchase of blood
  • Transportation of imported medicines
  • Repatriation Benefit & Funeral Expenses
  • Burn injuries
  • Mobility cover (prosthetic/artificial devices and/or orthopedic braces to enable the mobility of the insured
  • Fracture expenses 
  • Domestic road ambulance
  • Reconstructive surgery
  • Home/Vehicle modification expenses

Rider Benefits (OPTED BY THE INSURED WITH COST TO PREMIUM)

The following could be offered to specific needs as the insured may perceive, but additional premium will be loaded.

  • Life support benefit
  • Hospital cash allowance
  • Adaptation allowance
  • Accident hospitalization
  • Winter sports cover
  • Home convalescence
  • Loss of employment benefit

Procedure for Pre-Claim Filing (Important pre-filing procedures)

  • Hospitalization benefit can be availed of only if the policyholder is admitted within 7 days of the accident and is hospitalized for at least 24 hours. 
  • After the accident, one also has to submit  the following; 
  • Doctor’s certificate for the disability that prevents one from attending work
  • F.I.R
  • Policy copy
  • Claim form duly filled & signed by the insured/claimant/nominee
  • Post-mortem report (in case of accidental death)
  • Death Certificate
  • Spot Panchnama (certified copies)
  • Medical/Hospital report
  • Discharge Card
  • Doctor’s prescription
  • Medical/Pharmacy Bill
  • Any other document required by the relevant insurance company to process the claim

The following important points needs to be looked into

  • Contrary to public perception, premium paid on the Personal Accident Insurance Policy is NOT ELIGIBLE for any Income Tax benefits.
  • This kind of policy is not much canvassed by Insurance Agents as commission paid on such policies to them by the insurance company is too low.
  • For buying this policy, no medical checkup is required to be undertaken by the insured.

These policies can be purchased ONLINE & portability option is also available.

Do you Know Your ATM Card (Debit Card/Credit Card) Comes with Accident Insurance Cover?

In today’s time, most people use ATM cards. Due to ATM, we do not need to carry a lot of money with us. Money can be withdrawn anytime and anywhere with the help of this facility. But the ATM card does not work only for withdrawing money. Many other facilities are also available with the ATM card, whose information is not given to us. One of these facilities is your Accidental Insurance.

Yes, whether the ATM card is of a private bank or a government bank, complimentary insurance cover is also available with each card. This accidental cover can be from 25 thousand to 20 lakh rupees. The amount of insurance is decided according to the category of ATM card. In case of death or accident of the ATM card holder, this insurance can also prove to be the support of the dependents. Let’s know about it.

How do I make a claim?

The only condition for availing of the accidental hospitalization or death insurance cover is that the card should have been in use within 90 days prior to the accident. For the insurance cover to be applicable, the debit or credit card could have been used either at ATM, point of sale (PoS) or on e-commerce platforms, within the mentioned 90-day period.

The claim can be made bank branch where the cardholder has an account. It is not be noted that the claim has to be made no later than 90 days of the accident. Any claim made after 90 days might be rejected. The beneficiary of the claim could be the nominee on the account of the cardholder or legal heir.

It is also to be noted that this claim made with the bank of the cardholder will not affect claim process of any other external insurance provider. The claim can be made by submitting some documents to corroborate accidental death or permanent disability.

For example, for availing SBI’s RuPay card insurance, the following documents are needed:

  • Claim Form duly completed and signed.
  • Original copy of Death Certificate.
  • Original or Certified copy of FIR / Police report giving description of the accident.
  • Original or Certified copy of Post Mortem Report along with Chemical Analysis/FSL reports wherever applicable.
  • Aadhar copies of Cardholder and Nominee.
  • Declaration from Card Issuing Banks duly signed by authorized signatory and bank stamp specifying that: 
  • Cardholder is holding a RuPay card on RuPay issued IIN and mention the 16 digit card number.
  • Compliance of 90 days transaction criteria (to be supported with transaction log/account statement from the bank’s system).
  • Nominee Name and his banking details (including Passbook copy).
  • Brief description of Accident as per FIR translated in English or Hindi. 
  • Bank official’s Name and contact details with email ID.

Related

Enquire Now

Form is temporarily not available. Please visit our contact page.
X
Enquire Now