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Home > Health Insurance
What is Health Insurance?
Health insurance is a legal agreement with a health insurance company that entitles you to receive payment or reimbursement for your healthcare expenses. It offers financial protection in case of accidents or illnesses by helping to cover costs like doctor’s services, medications, hospital care and special equipment.
Health insurance can also assist with rehabilitation hospital stays, home health care and routine check-ups. Additionally, it often covers preventive services like immunization and cancer screening without any additional cost.
Up to 75% of Indians cover their health expenditures from their own pockets.
Quick Links
- What is Health Insurance?
- Why Do You Need a Health Insurance Policy?
- Types of Health Insurance
- Key Features of Health Insurance Plans
- How Does Health Insurance Work?
- List of Health Insurance Companies Available in India
- Health Insurance Checklist
- Benefits of Health Insurance
- Best Health Insurance Plans in India
- Top Reasons to Buy a Health Insurance Plan
- What is Covered Under Health Insurance Plans?
- What is Not Covered Under Health Insurance Plans?
- Eligibility Criteria to Buy Health Insurance
- Health Insurance Terminologies
- Why Should You Buy Health Insurance Online?
- Factors to Consider While Buying Health Insurance Policy
- Factors That Affect Health Insurance Premium
- Documents Required to Buy Health Insurance
- Documents Required for Health Insurance Claim Process
- Claim Process of Health Insurance
- Government Health Plans in India
- Health Insurance Riders
- Types of Waiting Period in Health Insurance
- Frequently Asked Questions (FAQs)
Why do you need a Health Insurance policy?
According to a dataset published by Statistica on November 20, 2023, the Indian health insurance market size was 370 billion rupees in 2018 and is projected to reach over 2 trillion rupees by 2030, due to rising income levels, urban awareness and lifestyle-related health demands.
Covers Medical Care Expenses
Health insurance is crucial as it covers the expenses for medical care received by you on your dependents. Without it, you risk paying the entire cost of healthcare on your own.
Affordable Rates
Health plans have a network of doctors and facilities with lower rates and reduced costs.
In-network Preventive Care
A health insurance plan encourages regular check-ups and preventive care to identify health issues early. Most plans cover 100% of in-network preventive care.
Tax Savings
Health insurance premium payments can be tax deductible under Section 80D of the Indian Income Tax Act.
Types of Health Insurance
There are 12 different types of health plans available in India to meet your unique healthcare needs.
01
Individual Health Insurance Plan
Designed to provide coverage for a single person, offering a range of benefits, such as doctor visits, prescription drugs, preventive care and more.
02
Family Floater Health Insurance Plan
Provides coverage for the entire family, including the spouse, children and parents under a single policy, making it convenient and cost-effective.
03
Senior Citizen Health Insurance Plan
It is specifically designed to provide health coverage for individuals above the age of 65. It offers various benefits including coverage for pre-existing conditions, hospitalization and medical expenses.
04
Critical Illness Insurance Plan
This insurance plan provides important financial protection in the event of a serious illness. It provides coverage for expenses such as hospital stays, surgeries and rehabilitation.
05
Group Health Insurance Plan
These plans provide a way to access healthcare coverage collectively for a group of people, such as a company’s employees. By pooling together, the group can often secure better rates and benefits compared to individuals purchasing insurance plans on their own.
06
Top-up Health Insurance Plan
These plans are beneficial for individuals seeking a financial safety net for medical expenses beyond their current insurance coverage. These ensure comprehensive protection against unforeseen healthcare costs.
07
Personal Accident Cover
Covers for personal accidents include protection for individuals who may experience partial or total disability or even death as a result of an accident.
08
Maternity Health Insurance Plan
This provides coverage for all expenses from the prenatal stage, including pre-natal checkups and tests, to the delivery of the baby and also covers the postnatal stage, including hospitalization and any necessary follow-up care.
09
Mediclaim Insurance Plan
It typically covers in-patient expenses such as room rent, nursing charges, doctor’s fees and various medical tests and procedures during hospitalization.
10
Disease-specific
People who are looking for insurance coverage tailored to a particular health condition, such as diabetes or cancer, may be interested in disease-specific insurance plans that cover the specific needs related to their conditions.
11
Hospital Daily Cash
In this, the insurer provides a daily allowance to cover expenses during hospitalization, helping to ease the financial burden on the insured.
12
Unit Linked Insurance Plan
It is a type of insurance product that combines the benefits of insurance and investment into a single integrated plan.
Health Insurance Calculator
Key Features of Health Insurance Plans
| Feature | Description | Impact on You |
|---|---|---|
| Sum Insured (Coverage Amount) | This is the maximum amount the insurance company will pay towards your medical expenses. | This determines the extent of your financial protection in case of hospitalization. Choose a sum insured that adequately covers potential medical costs. |
| Pre-Existing Conditions | These are medical conditions you have before buying the policy. Coverage for these may have waiting periods or exclusions. | Consider if your plan covers pre-existing conditions and any waiting periods that apply. |
| Room Rent Limits | This sets a limit on the daily room rent the insurance company will cover during hospitalization. | This can impact your choice of hospital room. If a higher room category is preferred, you may need to pay the difference. |
| Co-payment Clause | This requires you to share a portion of the claim amount with the insurer. | Reduces your out-of-pocket expenses, but you will still have some financial responsibility. |
| Network Hospitals | These are hospitals that have tie-ups with the insurance company for cashless hospitalization. | Allows for claim settlement directly between the insurer and hospital. Offers a hassle-free experience during hospitalization. |
| Pre and Post Hospitalization Expenses | Covers medical costs incurred before admission (diagnostic tests) and after discharge (follow-up consultations). | Provides more comprehensive coverage for your medical journey. |
| No Claim Bonus (NCB) | A reward for not making claims in a previous policy year. It translates to a discount on your health insurance premium. | Loyalty incentive that reduces your premium cost over time. |
| Policy Exclusions | Certain medical conditions, treatments, or expenses may not be covered by the policy. | Review the exclusions carefully to understand what's not covered. This helps you avoid claim rejections. |
| Claim Settlement Ratio | This reflects the percentage of claims settled by the insurance company. | Indicates the insurer's efficiency in processing and approving claims. Choose a company with a high claim settlement ratio. |
| Deductible | This is a fixed amount you pay upfront before the insurance company starts covering your medical expenses. | Reduces your premium but increases your out-of-pocket costs for smaller claims. |
| Sub-limits | These are caps set on specific benefits within the plan, like ambulance charges or doctor's fees. | Ensure the sub-limits are sufficient to cover the expected costs associated with those benefits. |
| Maternity Benefit | Coverage for pregnancy-related expenses, including hospitalization, delivery, and newborn care. | Important for expecting parents or those planning a family. |
| Outpatient Department (OPD) Cover | It covers expenses for doctor consultations, diagnostic tests, and medicines incurred outside of hospitalization. | Provides coverage for non-hospitalization medical needs. |
| Critical Illness Cover | Provides a lump sum payout upon diagnosis of a critical illness like cancer or heart attack. | Offers financial support during a critical time. |
| Renewability | Whether the insurance policy can be renewed after the initial term expires. | Provides continued health insurance coverage as long as you pay the premiums. |
| Policy Term | The duration for which the health insurance plan provides coverage. | Choose a policy term that aligns with your needs and financial planning. |
| Policy Wording | The specific terms and conditions are outlined in the insurance policy document. | Carefully review the policy wording to understand your rights and obligations as a policyholder. |
| Lifetime Renewability | Guarantees policy renewal for your entire life, even if you develop a medical condition. | Provides long-term health insurance security, especially for those with pre-existing conditions. |
| Restore Benefit | In some plans, the sum insured is replenished after a claim is settled, allowing for further coverage during the policy term. | Increases your financial protection in case of multiple hospitalizations within the policy period. |
| Wellness Programs | Certain plans offer benefits like gym memberships, health check-ups, or discounts on preventive care. | Encourages a healthy lifestyle and may identify potential health issues early on. |
| Second Surgical Opinion Cover | Provides coverage for seeking a second medical opinion from a specialist for a critical illness diagnosis. | It allows you to make informed decisions about your treatment plan. |
| Multi-city Coverage | Extends coverage for hospitalization across various cities in India or even internationally (depending on the plan). | Provides flexibility for those who travel frequently or require specialized treatment outside their city. |
| Ayush Cover | Covers hospitalization expenses for treatment using traditional Indian medicine systems like Ayurveda and Homeopathy. | Provides an option for those seeking alternative treatment methods. |
| Cashless Claim Settlement Network | The extent of the insurer's network of hospitals offering cashless hospitalization facilities. | A wider network provides more options for choosing a preferred hospital for treatment. |
| Policy Customization | Ability to add optional riders or benefits to tailor the plan to your specific needs. | Allows you to personalize your coverage for better protection against specific health risks. |
| Disease Management Programs | Provides support and guidance for managing chronic conditions like diabetes or heart disease. | Helps you manage your health proactively and potentially reduce future healthcare costs. |
| Consumables Cover | Covers the cost of disposable items used during hospitalization, such as gloves, syringes, and catheters. | Reduces your out-of-pocket expenses for essential medical supplies. |
| Maternity Hospital Cash | Provides a fixed daily cash benefit during hospitalization for childbirth. | Offers additional financial support for pregnancy-related expenses beyond medical costs. |
| Automatic Premium Increase | Option for an automatic premium increase to adjust for rising medical inflation. | Ensures your sum insured retains its value over time, providing adequate coverage in the future. |
| Teleconsultation Cover | Covers the cost of online consultations with doctors. | Provides convenient access to medical advice from the comfort of your home. |
| Hospital Daily Cash | Provides a fixed daily cash benefit for each day of hospitalization, irrespective of the actual medical bills. | Offers additional financial support to cover non-medical expenses during hospitalization. |
| Reload Option | Allows you to top up your sum insured amount mid-term if needed. | Provides flexibility to increase your coverage as your healthcare needs evolve. |
How does Health Insurance Work?
Health insurance offers financial support during medical
emergencies by helping policyholders cover their healthcare
expenses. In India, there are various types of health insurance
plans, but they all work in similar ways.
Here are the steps involved in how health insurance functions:
Evaluate Your Needs and Financial Constraints
Assessing your needs and budgetary restrictions will help you make informed decisions and prioritize your expenditures accordingly. By carefully analyzing your needs and financial limits, you can ensure that you make realistic and responsible choices to meet your requirements within your available resources.
Selecting a Health Insurance Plan
There are several factors to consider when it comes to selecting a health insurance plan. It is important to assess your medical needs and preferences, as well as your financial situation. Research different plans to compare coverage options, costs and network providers. Additionally, take into account any potential life changes or specific health conditions that may require special consideration.
Choose the Insured Amount
Please specify the amount you would like your insurance to cover. This sum insured amount will determine the extent of coverage provided under the policy. It is important to consider your assets and potential liabilities when selecting the sum insured.
Select Your Preferred Add-On Options
You can choose from a wide range of add-on options. Whether you want to include additional features, upgrade your package or enhance your services, there is something for everyone. Select the add-ons that best suit your needs and create a personalized package that meets all your preferences. Take advantage of the flexibility and customization that are offered to make the most out of your chosen plan.
Regularly Pay Your Premiums
Pay your premium amount regularly to ensure that your insurance policy remains active and provides you with the coverage you need. Setting up automatic payments or reminders can help you to stay on track and avoid any lapses in coverage.
Use Health Insurance for Medical Emergencies
In case of a medical emergency, you can rely on your health insurance plan to provide coverage and financial support. It is important to be aware of the details and benefits of your plan so that you can make the most effective use of it during an emergency.
The premium amount is calculated based on several factors including the sum insured, the insured person’s age, coverage benefits, deductibles and add-on riders. These variables help to determine the level of risk and potential cost of providing coverage. It is important to carefully consider these factors when selecting an insurance policy to ensure it aligns with your needs and budget.
Choose the Best Health Insurance Plan
that provides all the necessary coverage benefits you need at affordable premiums.
List of Health Insurance Companies Available in India
There are 13 health insurance companies in India providing health insurance plans. Each health insurance company offers its own health plan with some unique features and benefits. So, we have compiled a list of all the health insurance companies available in India with their claim settlement ratio, customer rating, and network hospitals.
| S.No. | Company Name | Claim Settlement Ratio (Latest Available) | Network Hospitals | Total Plans |
|---|---|---|---|---|
| 1. | 10% Claims Settled in the Year 2021-22 | 10+ Network Hospitals | 5 | |
| 2. | 10% Claims Settled in the Year 2021-22 | 10+ Network Hospitals | 0 | |
| 3. | 10% Claims Settled in the Year 2021-22 | 10+ Network Hospitals | 2 | |
| 4. | 10% Claims Settled in the Year 2021-22 | 10+ Network Hospitals | 3 | |
| 5. | 10% Claims Settled in the Year 2021-22 | 10+ Network Hospitals | 2 | |
| 6. | 10% Claims Settled in the Year 2021-22 | 10+ Network Hospitals | 2 |
*Claim Settlement Ratio data may vary depending on the source. It's recommended to check the company's latest annual report for the most accurate data.
Health Insurance Checklist
Consider these important factors when selecting a health insurance plan. Weighing these factors will help you make an informed decision that safeguards you from financial struggles and ensures adequate coverage during medical emergencies.
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Coverage amount
This is crucial as it determines the maximum payout for medical expenses. It is important to select a plan with a coverage amount that adequately addresses your potential medical requirements.
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Exclusions
Certain medical conditions or treatments may not be covered by some health insurance plans. It is essential to thoroughly review the list of exclusions before making a plan selection.
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Network hospitals
Choosing to receive treatment at a network hospital often results in lower expenses for the patient as they can benefit from the discounted rates negotiated between the hospital and the insurance company.
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Co-payments
It is important to be aware of the co-payment amounts and which services they apply to when managing your healthcare expenses.
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Room restrictions
It is important to review your insurance policy to understand the specific room restrictions that apply to your coverage.
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Disease coverage
Check if the plan covers the specific diseases that matter to you the most.
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Pre and post-hospitalization care
Comprehensive coverage like pre and post-hospitalization care can be beneficial for individuals seeking a more holistic approach to their healthcare needs, ensuring they receive necessary support before and after their hospital stay.
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Waiting periods
Health insurance plans often require a waiting period before certain benefits can be claimed.
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Daycare treatments
Some plans cover daycare treatments, such as chemotherapy or dialysis. Certain plans may include coverage for daycare treatments like chemotherapy or dialysis.
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Restoration benefits
Restoration benefits can be a great feature in insurance plans, as it ensures that your coverage amount will be replenished after you have used it up. It is important to carefully review the specifics of restoration benefits within an insurance plan to understand how it applies to your coverage.
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Bonus coverage
Certain plans provide additional coverage options, including dental and vision care benefits.
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Free health checkups
Certain insurance plans provide complimentary health checkups, ensuring that policyholders can access preventive and diagnostic services without additional costs.
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Do not just focus on getting the cheapest plan
Consider more than just the cost when selecting a health insurance plan. It is important to prioritize a plan that provides adequate coverage for your specific medical requirements.
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Get a family floater plan if you have dependents
If you have dependents, it is advisable to opt for a family floater plan. This type of plan provides coverage for both you and your dependents under a single policy.
Benefits of Health Insurance
Healthcare costs continue to increase, making it increasingly probable that individuals will encounter costly medical procedures at some point. Consequently, obtaining health insurance is a sensible approach to offset the burden of hefty medical expenses. When considering buying a health insurance policy, it is crucial to understand the various advantages that it offers.
Covers Hospitalization Expenses
Covers hospital costs, including room, doctor, surgery, ambulance and pre/post hospital expenses, relieving the burden of expensive bills during emergencies.
Cashless Treatment
Many insurance plans offer cashless hospitalization, eliminating upfront payment at network hospitals.
Tax Benefits
Health insurance premiums can be tax deductible in countries like India which helps in saving you money.
Security and Reduced Stress
It provides peace of mind and financial protection in case of illness or injury, reducing stress and allowing focus on recovery.
Access to Quality Care
Some insurance plans cover network hospitals and doctors for better healthcare services.
Preventive Care
Some plans cover preventive health check-ups, helping to identify potential health problems early for better overall health outcomes.
Coverage for Specific Needs
Offer additional coverage for critical illnesses and maternity care, addressing specific health needs.
Rewarding Healthy Habits
Some plans reward healthy habits with better insurance benefits.
Best Health Insurance Plans In India
When it comes to the best health insurance, there is no “one-size-fits-all” policy. It is like choosing a Netflix or OTT plan - different plans offer different benefits and have different costs. However, this age is designed to meet the diverse needs of most users, making it a versatile and comprehensive health insurance comparison page.
It is essential to conduct a thorough comparison to find the policy that best suits your needs. We have created a comprehensive table of how some of the top mediclaim policies in India compare to others in the industry.
| Insurance Provider | Plan Name | Coverage Type | Sum Insured Range | Age Limit (Adults) | Important Parameters | |
|---|---|---|---|---|---|---|
| Care Advantage Health Insurance Plan | Individual & Family Floater | ₹2 Lakh - ₹6 Crore | 18-65 years |
|
Check Premium | |
| ICICI Elevate Health Insurance Policy | Individual & Family Floater | ₹2 Lakh - ₹6 Crore | 18-65 years |
|
Check Premium | |
| IFFCO Tokio Family Health Protector Policy | Individual & Family Floater | ₹2 Lakh - ₹6 Crore | 18-65 years |
|
Check Premium | |
| Niva Bupa Aspire Policy | Individual & Family Floater | ₹2 Lakh - ₹6 Crore | 18-65 years |
|
Check Premium | |
| Arogya Supreme Policy | Individual & Family Floater | ₹2 Lakh - ₹6 Crore | 18-65 years |
|
Check Premium | |
| TATA AIG Medicare Lite Policy | Individual & Family Floater | ₹2 Lakh - ₹6 Crore | 18-65 years |
|
Check Premium |
Top Reasons to Buy a Health Insurance Plan
The importance of prioritizing health and financial security cannot be overstated in today's world. Investing in a health insurance plan is crucial as it provides a safety net against unexpected medical expenses. With a health insurance plan, you can receive the best possible care without having to worry about the financial burden it might impose. Considering these reasons, it is clear that having a health insurance plan is essential for safeguarding your well-being and financial stability.
01
Financial Protection Against Medical Costs
Health insurance covers expensive medical treatments, providing peace of mind during challenging times.
02
Coverage for Hospitalization Expenses
Health insurance covers hospital costs, reducing financial burden during illness.
03
Protection Against Rising Medical Inflation
Medical care costs are rising. Health insurance protects against inflation. The insurance company covers rising treatment costs, ensuring quality healthcare without financial hardship.
04
Tax Benefits
Health insurance premiums in many countries can be tax deductible, reducing your overall tax payment and making it more appealing.
05
Peace of Mind and Better Treatment Options
Health insurance allows prompt access to medical care regardless of cost. Timely treatment improves health outcomes and enables informed decision-making.
06
Comprehensive Coverage Options
Choose a health insurance plan with coverage options, including pre-hospitalization, pre and post-hospitalization expenses, ambulance services and cashless treatment at network hospitals, suiting your needs and budget.
07
Additional Benefits
Health insurance plans may have extra benefits such as preventive checkups, maternity coverage and coverage for alternative therapies, which can improve your health and well-being.
What is Covered Under Health Insurance?
In the below section, you will get an insight into the coverage offered under the health insurance in India:
- In-Patient Hospitalization
- Pre and post-hospitalization
- Annual Health Check-Ups
- No Claim Bonus (NCB)
- Day Care Treatments
- Domiciliary Hospitalization
- Additional cover
- Tax Exemption
What is not covered under Health Insurance plans?
The following situations and conditions are not covered under Health Insurance Plans:
- Pre-existing Diseases
- Self-Inflicted Injury
- Injuries Due to Consumption of Alcohol
- Transmitted Diseases
- Pregnancy Treatment
- Infertility Treatment
- Congenital Diseases
- Permanent Exclusions
- Cosmetic Surgery
Eligibility Criteria to Buy Health Insurance
Health insurance plays a vital role in providing financial
protection during medical emergencies. It is important to have a
clear understanding of the eligibility criteria before choosing a
health insurance plan in India.
This will help ensure that you find the right coverage that meets
your specific needs.
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Age
Minimum Age: In India, the minimum age to buy health insurance is 18 years
Maximum Age: It is 60 to 65 years and varies by company and plan. Some insurers offer special plans for seniors
Dependents: Newborn babies can have health insurance from 15 days after being born. The age limit for child dependents varies which usually goes up to 18 or 25 years, depending on the plan
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Pre-Existing Medical Conditions
Disclosure: Disclose pre-existing conditions during the application process to avoid future claim rejections
Impact on Eligibility: Pre-existing conditions may impact eligibility for health insurance but not necessarily disqualify you. Factors like coverage and costs can be affected.
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Medical Tests
Younger Applicants: People under 45 years old often do not need to take medical tests when they apply for health insurance.
Older Applicants or Pre-Existing Conditions: Insurance companies may request medical tests for older or pre-existing conditions of applicants to evaluate the risk before issuing a policy.
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Other Factors
Insurance companies may take into account additional factors like smoking, tobacco use or high-risk occupations when assessing eligibility for setting premium costs. These lifestyle habits and occupational factors can impact the level of risk associated with insuring an individual, leading to adjustments in the coverage terms or pricing.
Health Insurance Terminologies
Understanding health insurance terminology can be crucial for making
informed decisions about healthcare coverage.
Here are some common terms and their definitions:
Insurance:
It is a binding agreement between an individual and a health insurance company, wherein the insurer commits to covering specific medical costs in return for a regular premium.
Policy:
The health insurance plan document specifies the terms and conditions of your coverage, including the benefits, costs and any services that are not covered.
Premium:
The amount of money you pay to your insurance company regularly to keep your health insurance coverage active. It is typically paid monthly, quarterly or annually depending on the terms of your policy.
Deductible:
It is an essential component of your health insurance plan, determining the amount you will need to pay for covered medical services before your insurance starts contributing.
Copayment (Copay):
It is a predetermined fixed amount that you pay for specific covered medical services like doctor visits or prescriptions.
Coinsurance:
The portion of covered medical expenses that you are responsible for paying after meeting your deductible, in partnership with your insurer. This typically involves a split, such as an 80/20 coinsurance clause where the insurance company covers 80% and you 20% after the deductible has been met.
Benefits:
Covers medical services like hospitalization, doctor visits, surgery, prescriptions and more.
Network:
A group of healthcare providers, such as hospitals and doctors, with whom the insurer has arranged discounted rates. When you use in-network providers, you can expect to pay less out of pocket for your healthcare services.
Out-of-network:
When you utilize healthcare providers who are not within your insurer’s network, you can expect to incur higher out-of-pocket expenses.
Pre-existing Condition:
A medical condition that existed before getting health insurance. Some plans may not cover pre-existing conditions immediately or have specific waiting periods.
Claim:
It is essentially a formal request that you submit to your insurance company to seek reimbursement for medical expenses that are covered by your insurance policy.
Explanation of Benefits (EOB):
It is a crucial document provided by your insurer, offering a comprehensive breakdown of a processed claim.
Out-of-pocket Maximum:
It is a crucial factor to consider when choosing a health insurance plan. It represents the most you will have to pay for covered services in a plan year after you have met your deductible and coinsurance.
In-network Benefit:
It can reduce out-of-pocket expenses for healthcare services, as the insurer pays a pre-negotiated rate for covered services received from in-network providers.
Pre-authorization:
It is a necessary step to obtain coverage for certain non-emergency medical services from your insurer. It is essential for avoiding unexpected out-of-pocket expenses and ensuring that the services are within the scope of your plan’s coverage.
Maximum Lifetime Benefit:
It is a limit on the total sum an insurance provider will pay for covered benefits throughout your lifetime.
Why Should You Buy Health Insurance Online?
The benefits of purchasing insurance online include convenience, time-saving, access to a wide range of options and cost-effectiveness. Let us discuss these features of online health insurance purchases in detail.
Affordable Option: Buying health insurance online eliminates additional costs associated with the offline process, making it more cost-effective. Simply visit the official website, follow the process and pay the premium to bypass brokerage, commission and other expenses.
Act as an Agent Yourself: You do not need an insurance agent anymore with online information availability and policy purchasing options. Avoid paying commissions and prevent fraudulent cases by purchasing insurance online.
Improved Transparency: Customers expect transparency in health insurance policy details, which are easily available online without the need for agents. Contact our health insurance toll-free number for further information.
Check Status Online: Easily check the policy status and renew online without leaving home.
Time Efficient: The offline policy requires a branch visit but online health insurance is quick and hassle-free with an internet connection and device.
Improved Customer-Company Communication: Customers must provide accurate information when buying insurance to ensure transparency, better coverage and lower risk of claim rejection.
Easy Access: No time restrictions for online insurance purchases. No need to visit the branch during office hours. Online platforms stay open for 24 x 7 for buying or renewing health insurance.
Factors to Consider While Buying Health Insurance Policy
Safeguarding your health is crucial as medical costs rise. Health insurance provides protection and access to quality healthcare, but choosing the right policy can be overwhelming. Consider the following key factors before deciding.
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Age and Medical History
Take into account your age, any pre-existing conditions and your family’s medical history. These elements play a crucial role in determining your risk profile and the specific type of coverage that suits your needs.
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Lifestyle Habits
If you engage in high-risk activities or have unhealthy habits, it is important to consider the potential coverage for any injuries or illnesses that arise as a result.
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Hospitalization Expenses
Make sure that the policy you choose comprehensively covers all your hospitalization expenses, such as room rental, surgeon fees and anaesthesia costs.
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Pre and Post-Hospitalization
Choose a plan that includes coverage for pre-hospitalization diagnostic tests and post-hospitalization care. These benefits are crucial for comprehensive healthcare coverage.
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Daycare Procedures
Certain procedures only require a stay of one day. Select a policy that includes coverage for daycare expenses.
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Critical Illness Coverage
You should consider adding a rider for critical illnesses such as cancer or heart disease to provide additional financial protection.
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Exclusions
Take a close look at what the policy does not cover, such as specific treatments, pre-existing conditions with waiting periods or self-inflicted injuries.
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Sum Insured
This represents the maximum amount that the insurer will pay for covered medical expenses. It is crucial to consider the impact of increasing medical inflation and anticipate future healthcare needs when determining the sum insured.
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Customer Service
Conduct thorough research on the insurer’s reputation for customer service to guarantee quick claim processing and reliable assistance.
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Premium
It is the price of the policy. It is usually dependent on factors such as your age, health condition, coverage choices and insured amount.
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Deductible
This is the amount you pay upfront before the insurance company begins sharing costs. Opting for a higher deductible reduces your premium, but it also means you will be responsible for more initial expenses.
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In-Network Providers
It refers to hospitals and clinics that have made agreements with the insurance company to provide services at discounted rates. When you choose in-network providers, you can significantly lower your out-of-pocket expenses. This is a smart way to save on healthcare costs while still receiving the quality care you need.
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Out-of-Network Providers
Receiving treatment at hospitals or clinics that are not included in the insurer’s network usually results in higher expenses.
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Cashless hospitalization
Make sure to opt for a health policy that includes cashless hospitalization. This feature allows the insurer to directly settle the bill with the hospital, eliminating the hassle of out-of-pocket payments. Enjoy the convenience and peace of mind that comes with a policy that offers cashless hospitalization.
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Claim Settlement Ratio
Conduct thorough research on the insurer’s claim settlement ratio, as it serves as an indicative measure of the percentage of claims they approve. A higher ratio signifies superior claim settlement practices.
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Renewability
Guarantee that the policy is renewable for life or until an advanced old age to eliminate any gaps in coverage.
Factors that affect health Insurance Premium?
Understanding the various factors and circumstances that affect the calculation of your health insurance premiums is essential. By being aware of these factors, you can make informed decisions and maximize the benefits of your policy.
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Age of the Insured
Age is a major factor that determines health insurance premiums. As people get older, the risk of mortality, hospitalization and medical expenses increases.
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Type of Plan Chosen
Health insurance premium varies based on the chosen plan. Family floater plans cost less than individual policies due to higher sickness probability. The premium depends on the oldest member’s age in the family floater plan.
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Sum Insured
Choosing a lower sum insured for health insurance can result in a lower premium, but you will have to pay extra out of your pocket if your medical bills exceed that amount.
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Habits and Lifestyle
Smoking, chewing tobacco or snuff will increase your premium due to a higher risk of lung infections, cancer and critical illnesses.
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Pre-existing Diseases
People with pre-existing medical conditions pay higher premiums due to increased hospital expenses and medical bills. The severity and type of condition determine the amount of premium increase.
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Co-payment
Health insurance co-payment is the percentage of the claim amount you pay, while the insurer covers the rest.
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Add-on covers
Health insurance add-ons enhance existing policies for an extra premium, with a limit of 30% of the original premium for all add-ons combined.
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Family Medical History
A family history of illnesses like heart disease, cancer, Alzheimer’s etc can increase your risk of contracting illnesses. As a result, your premium rates may also be higher.
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Where You Live (Zones)
Geographic locations differ in risks, medical costs and environmental factors. In India, cities are divided into zones, based on medical expenses. High expenses correspond to higher zones and premiums.
Documents Required for Buy Health Insurance?
Remember to submit the necessary documents for your health insurance policy, both during the purchase and when making a claim. Keep this health insurance document checklist in mind when selecting the right plan.
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Identity Proof :
Aadhar Card/Passport/Voter ID Card/Driving License
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Age Proof :
Aadhar Card/PAN card/Passport/Driving License/Voter ID Card/Birth certificate
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Address Proof :
Driving License/Ration Card/Aadhar Card/PAN Card/Passport/Rent agreement, if applicable/Utility bills like electricity bill or telephone bill
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Other Important Documents:
Passport-size photographs (if demanded by the insurer)/Medical reports (if demanded by the insurer)/Proposal form duly filled in and signed
Documents required for Health Insurance Claim Process?
The documentation needed in the case of a reimbursement claim are as follows:
- Filled out insurance claim form with an accurate signature
- Accepted identity proof like Aadhar, PAN, passport, driver’s license or voter’s ID
- Original policy documents containing the policy number, insured’s name and coverage details
- Hospital document that summarizes diagnosis, treatment, and stay
- Doctor's notes, test reports, and prescriptions are part of medical records
- Original, stamped, signed hospital bills are necessary
- Keep payment receipts for hospitalization payments
- Form for a pre-authorization claim submitted to the insurer for approval before hospitalization
- For an accident claim, you may need the FIR copy
- MLC is a doctor's document for medico-legal cases
- Multiple health insurance policies may require a settlement certificate from the first insurer.
Claim process of Health Insurance
To ensure a seamless cashless claim experience with your health insurance, follow these steps:
Ensure you enrol in a hospital within your insurance network by reaching out to the insurance helpdesk and seeking their guidance.
to verify your identity, simply present the health card issued by your insurer in this step.
The hospital will give you a pre-authorization form to fill out if you want to avail of their cashless service.
After completing the pre-authorization form, it should be submitted to the insurance desk at the hospital.
After you have completed the form, the hospital will send it to your health insurance provider for further processing.
The insurer carefully reviews the request and accompanying documents. If everything meets the policy requirements, the insurer approves the cashless claim.
Settle any out-of-pocket expenses that are not covered by your insurance policy when you are discharged.
In the final step, the insurer will complete the payment process and settle the bill with the hospital based on the terms outlined in the policy agreement.
Government Health Plans in India
The Indian government offers a variety of health insurance schemes. Here's a look at some prominent schemes:
Ayushman Bharat
This is a government initiative that focuses on extending health coverage to low-income families in India. The programme provides financial protection by offering coverage of up to 5 lakh rupees per annum for hospitalization costs at empanelled hospitals. This initiative aims to ensure that families have access to healthcare services without facing financial burdens.
Awaz Health Scheme (Kerala)
This scheme in Kerala provides essential medical insurance and accidental death coverage to migrant workers, ensuring they have access to healthcare and financial support in the event of an accident. This initiative aims to improve the well-being and security of migrant workers in Kerala, acknowledging their valuable contributions to the state’s economy and society.
Aam Aadmi Bima Yojana
This scheme offers life insurance coverage to individuals engaged in certain professions such as carpentry, fishing and 48 other vocations. It aims to provide financial security to people working in these specific fields.
Rajasthan Health Insurance (Bhamashah Swasthya Bima Yojana)
This is a government programme in Rajasthan that provides health insurance to individuals living in rural areas. It assists in covering hospital expenses without imposing any age restrictions.
Central Government Health Scheme
This is a comprehensive plan specifically designed to cover medical expenses for central government employees and pensioners. It provides coverage for hospital stays, home care and medical bills in 71 cities. Additionally, the scheme encompasses both traditional and alternative medicine, ensuring a wide range of healthcare options for its beneficiaries.
Tamil Nadu Chief Minister's Health Insurance
This plan offers financial support to families in Tamil Nadu, providing coverage for healthcare expenses of up to 5 lakh rupees per year. Designed for individuals earning less than 75,000 rupees annually, the plan also facilitates cashless treatment at select hospitals.
Employee Health Insurance
This health insurance programme offers financial assistance to factory workers in India who face illness, disability or death.
Kerala Critical Illness Insurance
This illness insurance programme provides financial assistance to low-income families facing major health conditions such as cancer or heart disease.
Maharashtra Health Insurance (Mahatma Jyotiba Phule Jan Arogya Yojana)
This is a government initiative that provides coverage for medical expenses up to 1.5 lakh rupees for impoverished families and farmers in the state of Maharashtra.
Gujarat Health Insurance (Mukhyamantri Amrutum Yojana)
This programme is specifically designed to assist low-income families in paying for their hospital bills. This initiative provides coverage of up to 3 lakh rupees per year, ensuring families have access to the necessary medical treatment without incurring excessive financial burden.
Accidental Death and Disability Insurance (Pradhan Mantri Suraksha Bima Yojana)
This accidental death plan offers affordable coverage for accidental death and disability. This plan is available to individuals aged 18 to 70 who hold a bank account. It serves as a financial safety net in case of unforeseen accidents resulting in death or disability.
Andhra Pradesh Health Insurance Programs
This plan is for low-income families or individuals who are above the poverty line. Additionally, there are specific plans available for journalists and state government employees.
Telangana Government Health Scheme
This plan is specifically designed to provide medical coverage for both current and retired government employees and journalists in Telangana. Beneficiaries of this scheme have the convenience of availing cashless treatment at network hospitals, ensuring easy access to quality healthcare services without financial burden.
National Health Insurance for Informal Workers
This programme aims to offer health insurance coverage to individuals and their families working in the informal sector with low incomes. This initiative aims to provide financial protection and accessibility to healthcare services for those who typically lack access to formal employment benefits.
Universal Health Insurance (For Very Poor)
This health insurance programme in India provides health coverage for hospitalization, accidents and disability to families living in extreme poverty.
Karnataka Farmer Health Insurance
This plan is designed to provide financial assistance to farmers in Karnataka for their medical expenses. With coverage for over 800 medical procedures at network hospitals, it offers comprehensive support for their healthcare needs.
West Bengal Government Employee Health Plan
This program provides comprehensive medical coverage for government employees, prisoners and their families. The programme includes cashless treatment for outpatient care and surgeries, except cosmetic procedures. It aims to ensure access to quality healthcare services for eligible beneficiaries without the financial burden of medical bills.
Please note: This list is not exhaustive. It's recommended to research specific schemes for detailed information and eligibility criteria.
Health Insurance Riders
Health insurance riders are extra provisions that enhance a basic health insurance policy by offering additional coverage or benefits. These riders include various options that can be customized to meet specific needs and preferences. Common examples of health insurance riders include dental and vision coverage, maternity coverage and prescription drug coverage. Adding these riders ensures individuals have comprehensive healthcare protection tailored to their unique requirements.
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Critical Illness Rider
Provides a lump-sum benefit for specified critical illnesses like cancer, heart attack or stroke covering treatment costs and other expenses.
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Accidental Death and Dismemberment (AD&D) Rider
Provides financial benefits for accidental death or severe injury resulting in loss of limbs or bodily functions.
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Hospital Indemnity Rider
Provides cash benefit for extra hospital costs not covered by standard insurance.
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Prescription Drug Rider
Reduces out-of-pocket expenses for necessary medications not covered by basic health insurance.
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Preventive Care Rider
Covers preventive services early disease detection and prevention.
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Vision and Dental Care Rider
Coverage for routine eye exams, glasses, contact lenses, dental check-ups, cleanings and other dental procedures.
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Rehabilitation Services Rider
Covers physical and occupational therapy post injuries or surgeries.
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Long-Term Care Rider
Covers extended care services such as nursing home care, home healthcare and assistance with daily living activities, essential for long-term care planning.
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Waiver of Premium Rider
Premium payments are waived if the policyholder becomes critically ill or disabled.
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Term Conversion Rider
Allows converting term life insurance to permanent without medical exam or long-term coverage stability.
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Exclusionary Rider
It offers restricted coverage for specific events or conditions, but it is mostly prohibited under the Affordable Care Act for healthcare insurance.
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Critical Illness Rider
Provides a lump-sum benefit for specified critical illnesses like cancer, heart attack or stroke covering treatment costs and other expenses.
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Accidental Death and Dismemberment (AD&D) Rider
Provides financial benefits for accidental death or severe injury resulting in loss of limbs or bodily functions.
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Hospital Indemnity Rider
Provides cash benefit for extra hospital costs not covered by standard insurance.
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Prescription Drug Rider
Reduces out-of-pocket expenses for necessary medications not covered by basic health insurance.
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Preventive Care Rider
Covers preventive services early disease detection and prevention.
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Vision and Dental Care Rider
Coverage for routine eye exams, glasses, contact lenses, dental check-ups, cleanings and other dental procedures.
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Rehabilitation Services Rider
Covers physical and occupational therapy post injuries or surgeries.
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Long-Term Care Rider
Covers extended care services such as nursing home care, home healthcare and assistance with daily living activities, essential for long-term care planning.
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Waiver of Premium Rider
Premium payments are waived if the policyholder becomes critically ill or disabled.
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Term Conversion Rider
Allows converting term life insurance to permanent without medical exam or long-term coverage stability.
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Exclusionary Rider
It offers restricted coverage for specific events or conditions, but it is mostly prohibited under the Affordable Care Act for healthcare insurance.
Types Of Waiting Period In Health Insurance
Understanding waiting periods is crucial when selecting a health insurance plan. It is important to know the specifics about any waiting periods that may apply, as this can affect when coverage begins for specific services or conditions. Being informed about waiting periods will help ensure that the insurance plan meets the individual’s needs and expectations.
01
Pre-Existing Diseases (PED) Waiting Period
Health insurance covers pre-existing diseases after a waiting period of 2 to 4 years. This means hospitalization expenses for declared conditions can only be claimed after completing the waiting period.
02
Insurance for Specific Ailments/Procedures with Waiting Period
Health insurance may have waiting periods for specific conditions or procedures, like ENT disorders, hernia, joint replacement surgery and cataracts. Coverage starts after 1 or 2 years.
03
Initial Waiting Period
Health insurance plans usually have an initial waiting period, of one month, where only accidental claims are acceptable.
04
Critical Illnesses Waiting Period
Heath insurance covers critical illnesses after 90 days, with claims during this period usually rejected.
05
Maternity Benefit Waiting Period
Health insurance plans with maternity benefits often have a waiting period of 9 to 36 months before coverage can be used.
06
Health Check-Up Waiting Period
Some policies offer free health check-ups after 1 year of coverage. It is recommended to schedule the check-up at the beginning of the second year.
07
COVID-19 Waiting Period
Health insurance covers COVID-19 treatment after a 30-day wait.
08
Accidental Hospitalisation Waiting Period
No waiting period for accident hospitalization, insurance companies may waive it.
Frequently asked questions
- Cosmetic surgery
- Dental and vision care
- Pre-existing conditions
- War injuries
- Self-inflicted injuries
- Urgent care: It is designed to address non-life threatening medical issues promptly, without the extended wait times commonly experienced in emergency rooms. However, it is important to note that they may have limited resources for complex diagnostics. If you require immediate attention for a non-life-threatening illness or injury, urgent care could be a more efficient option.
- Emergency care: It is necessary for life-threatening situations or serious injuries that need medical attention. Emergency rooms are fully equipped to handle complex medical emergencies. However, it is important to note that emergency room visits can result in high costs. Therefore, understanding the distinction between emergency care and other levels of care can help you receive the appropriate treatment and potentially save money.
