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Ten questions you should ask your health insurance company

01.29.2014 · Posted in Finance, Insurance

You are diabetic and have recently developed renal complications that require in-patient care. You have health insurance coverage; so no worries about finances, you feel. Upon arrival at the hospital you are in for a big shock. Your health insurance policy does not cover complications of diabetes!

Given the fact that medical expenses at these times are so high, having a health plan is necessary to avert a financial disaster. However, Health Insurance coverage varies from company to company and among different health plans, so, it is better to be aware of all the pros and cons before you go in for a health insurance policy.

Here are some questions you might want to ask your health insurance company –

1. Does your health insurance cover accident, outpatient treatment expenses, ambulance expenses, surgery, and maternity care?
Although most insurance companies cover surgeries and accidents, they don’t include outpatient treatment, ambulance expenses, and maternity benefits in the policy. So, it is better to find out if your insurance company covers these. Also remember to ask them how much coverage is given. For example, some companies may give you maternity benefits but they limit the coverage to a low percentage of your total insurance cover.

2. What does a health insurance policy not cover?
Treatment of certain diseases is not covered during the first year of your policy. Many companies start covering them after a waiting period of 48 months of taking the policy. The list of diseases may vary from one health policy to another. So get a policy that best suits you. Some health insurances don’t cover pre-existing diseases. Make sure you understand well what diseases are covered and which ones are not. Most policies do not cover costs of contact lenses, spectacles and hearing aids, convalescence, general debility, congenital external defects, venereal disease, intentional self-injury, use of intoxicating drugs and alcohol, and AIDS.

3. What additional benefits and other stand alone policies does your health insurance company offer?

Find out what ‘add-ons’ or riders your insurance company offers. Benefits like “Hospital Cash”, “Critical Illness Benefits”, “Surgical Expense Benefits” etc. are provided by some companies. These come along with your policy or you may have to buy the policy separately. Some health insurance policies pay for specified expenses towards general health check up once in a few years. Get an update on that too.

4. What schemes are offered by the health insurance company?

Check out the health plans existing currently – individual and family schemes, group insurance schemes (generally taken by the corporate or large companies), senior citizens insurance schemes, long-term health care and insurance cover for specific diseases – and select the policy best suited to you. Most companies do not have separate health insurance cover for a child; they are covered in the family health insurance schemes.

5. How is your health insurance premium determined?

Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses. Previous medical history is also a determining factor, which means, if you don’t have prior medical history, premium will be lower. If you have not claimed for a number of years, the company may give you a discount on the premium. Ask for it.

6. Do you require a medical test for a health insurance plan?

Some health plans require a medical test while others may not make it obligatory. Whether or not you undergo medical tests, you will anyway be required to make a declaration about your health condition in the application form. And the premium rates are fixed based on your declaration. If you hide a health condition at the time of purchasing a policy, your claim may be rejected just on this basis.

7. Does your health insurance company provide cashless facility?
According to the Insurance Regulatory and Development Authority (IRDA), India – ‘Insurance companies have tie-up arrangements with a network of hospitals in the country. If policyholder takes treatment in any of the net work hospitals, there is no need for the insured person to pay hospital bills. The Insurance Company, through its Third Party Administrator (TPA) will arrange direct payment to the Hospital.’ Cashless hospitalization is available only in Network Hospitals. Find out what hospitals are available through the plan? Where is the nearest one in the network? How is emergency care handled?

8. What is the maximum number of claims allowed over a year?

Most insurance companies allow any number of claims but limited to the sum assured of your policy. Confirm it.

9. What are the documents required for Claims filing?

Generally, you will be required to submit –

  1. a completed and signed Claims form of the company,
  2. all original medical bills,
  3. all reports including medical reports, diagnosis, case histories, discharge summaries, etc.,
  4. medical services and treatments provided and their costs,
  5. drugs prescribed, and their costs.

Read the plan carefully and furnish all the documents required by them or your claim may be rejected / delayed because documents pertaining to your illness are either not proper or missing. Ask your health insurance company/ broker for detailed list of documents you’d need to submit.

10. What is the grace period if you miss a premium or don’t renew your policy in time?

If you don’t renew your policy in time, your policy lapses and you will have to buy a new policy. That would mean, increased premium, non-coverage of pre-existing diseases, and missing the bonus for claim free years. Ask your health insurance company about the grace period. Grace period varies from company to company – some allow for seven days, others may even extend it up to 15 days.

Do your own research, compare different health plans, and make sure you are aware of the policy terms and conditions of your health plan. As the saying goes – ‘The greatest wealth is health.’ Make a conscious choice.