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?

 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 1^stApril, 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.

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.