17 most important questions that you should know before buying Health Insurance

POSTED BY manish ON October 31, 2010 COMMENTS (112)

Are you confused about many things when it comes to Health Insurance in India ? Are you afraid of rules and regulation in Mediclaim policies ? Don’t you have a clear idea about how will you deal with various things in Health Insurance and delaying your decision of taking a Health Policy ?

Today we will look at most frequently asked questions in Health Insurance try to answer those questions.

health insurance

 

1. Can a person get claim from his own company and spouse company if they are covered under both companies ?

Yes, if both husband and wife are covered from their employer, they can claim from insurance provided to them by both the companies.

For e.g. if husband is covered for 1 lac under group insurance policy from his company (and her spouse is also covered under her husband company policy), and the same situation exists vice versa, both of them are then, actually covered for 2 lacs each; 1 lac from their company and 1 lac from their spouse’s company.

Now if something happens and husband gets hospitalized and expenses are 1.8 lacs, then husband can make a claim of 1 lacs from any one of the company and remaining 80k from other company. If you have cashless facility then you just show both health cards. If you don’t, you can get reimbursed by insurance company.

One important point worth noting is that during reimbursement, one should apply for the reimbursement first to his parent company and then to the one of his spouse. See some hidden health insurance policies

2. Do we have to notify the company about any illness or habit developed in between?

No, we are not required to notify the company regarding any complication or health issue. If the policyholder is hospitalized, the company will automatically come to know of it. Otherwise, no need to inform the company about any such policy.

If you notify the company, your premium for year after notification will increase, if it is under their list of illness to be checked. If you don’t notify the company and when you go for a claim, they will come to know that it was developed earlier and the claim will be settled accordingly and from next year onwards they might put loading on it (All these reasons vary from company to company).

So whether you tell them or not, it’s the same thing. They have doctors panels with whom they check your details before giving you the claim.

3. Does Health Insurance cover everything from accident, surgery, normal hospitalization ?

Yes, Health Insurance covers you for everything, provided you were hospitalized, be it for any reason; due to accident, illness, or disease. If someone met with an accident and he is hospitalized, then his mediclaim policy will pay for his bills, no exceptions.

Watch this video to know what are the things to look for while choosing a health insurance plan:

4. What are the advantages of sticking to one Health Insurance company for a long time ?

The plus point of sticking with one company is that if someone is suffering from any pre-existing disease at the time of commencement of policy, those complications will be covered after 4 years. Until portability is introduced in India, this is the single biggest advantage to stick with one company for long.

Another advantage is that when you have a continued policy from any insurance company, after few years you get bonus or discount in premium.

For example: Suppose you have a policy of 3 lacs and you are with the same insurer for past 4 years you can get a bonus of 50% i.e. you pay premium for 3 lac only but you get coverage of 4.5 lacs. Similarly some companies don’t offer bonus but they offer discount in premium i.e. for coverage amount of 3 lacs you pay lesser premium than actual amount.

So if you don’t have any serious problems with the insurance company then it is better to stick to one company.

5. Can NRI’s take health insurance? Can they travel to India for treatment and claim? What about emergency situations ?

Yes NRI’s can take Health insurance in India. They can definitely travel to India for treatment and can claim it. however they will have to show their residence proof, ITR and a few other documents. If they don’t have those documents, then they are not eligible to get insured in India.

The cost of treatment in India is different and cheaper than countries like USA, UK and other European countries. The premium amount computed depends on Indian conditions and parameters. So if a NRI has health insurance form Indian company, that person would be paying premium as per India actuaries and obviously cost of treatment in his residing country would be higher than India.

For example:

If a person get dengue and he is very critical and requires urgent hospitalization, the cost of treatment in India would come up to 1-2 lacs (and this is on higher side.) The same treatment would cost around 10-15 thousand dollars in US so this burns a hole in insurance companies’ pocket.

So for treatment the person has to come to India and they don’t offer compensation for treatment there. Some Rules about NRI insurance and Investments

6. How to claim successfully in case of emergency and planned hospitalization?

The most basic fundamental for a smooth claim process is keeping all your documents up to date. If you have a past history of illness, make sure that you submit those documents too, because the TPA department will come to know whether it’s a pre-existing disease or not.

While submitting your documents make sure that all the documents are proper and there is no missing document pertaining to your illness. This will just give a chance to TPAs to make excuses and you will have to run for your money.

It’s worth noting that in case of planned hospitalization, if you inform your mediclaim company in advance and take prior authorization, everything will be settled by the mediclaim company or TPA, without the policyholder been required to submit any document.

7. Is it better to take accidental policy separately or mix it with term insurance as a rider?

If your accidental policy is a rider with some Term insurance (9 most asked questions about Term Insurance) then you must take care that it covers everything what accidental policy should cover. Generally when a policy is offered as a rider it does not cover each and every aspect.

For example: An accidental policy offers insurance against partial disablement, loss of limbs, hands and many other parts. But in a rider, many insurance company offers insurance against permanent disablement only and not for partial disablement and loss of body parts.

Also note that, because accidental rider is much less if taken with Term Plan as compared to the personal accidental policy taken stand alone. Under term plan, accidental death benefit could be taken for as little as Rs.1000 for a cover of upto 15 lakhs where as in a stand alone policy the same amount will be available for a premium of around Rs.2000. So it depends.

8. What are the top most things one should check in the policy documents ?

The first thing one should have a look at, is to check what the exclusions in the policy are. This is because, we get information on what is covered but no insurance company will give information on what is not covered and this creates a problem at the time of claims. So to avoid any surprises, one should have a thorough look at exclusions as well.

For example: A new circular was passed by many insurance companies few months ago in which they provided only Rs.20-24 thousand (different companies had different rates) compensation for cataract operation. Earlier there was no limit on it.

So sometimes in list of coverage for health insurance we just read the tabular format given by companies but don’t go inside to see the details and this can land us in soup sometimes. Many insurance companies now provide Maternity benefits but they limit it to coverage of only Rs.20-30 thousand, we just see that maternity benefits are given but sometimes fail to notice how much coverage is given.

Also check if the policy has Loading and Co-pay .

9. If there are no loading charges, can premium still change on renewal?

This is a very big question with very easy answer..If you check the premium structure of any of the mediclaim company, either there premium is increasing every year or they have premium slab for different age groups; something like for age 30-35 premium is 4200 and from age 36-40 its 6700.

So under this second policy, when the policy holder moves from age 35 to 36, his premium suddenly jumps by Rs.2500 and this is not loading.

So yes, premium can/will increase irrespective of loading after certain age.

10. Is it a good idea to split health insurance into 2 policies? Tips?

No logic for doing this except personal preference. If you are taking another mediclaim policy just to increase your cover, why not get your cover amount enhanced in the existing policy/company.

Get another mediclaim policy only if certain other company is offering feature/features which your existing policy does not and you have surplus funds at your end to afford 2 separate mediclaim policies at a time. No other reason to, otherwise.

11 . During the course of my treatment, can I change the hospitals?

Yes it is possible to shift to another hospital for reasons of requirement, of better medical procedure. However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions. Note that it would be prudent if you check the network hospital list and go to the best hospital in the beginning itself rather than changing midway.

12. What are the situations under which one may be denied cashless hospitalization?

  1. If there is any doubt in the coverage of treatment of present ailment under the Policy if the information sent to TPA is insufficient to confirm coverage
  2. When the ailment/condition is not being covered under the policy.
  3. If the request for pre-authorization is not received by TPA in time. In such a situation, the Insured can take the treatment, pay for the treatment to the hospital and after discharge, send the claim to TPA for processing.
  4. In case the hospital in not on the panel of the company or the disease/illness is pre-existing and not covered for 4 years.

13. Whom can I approach in case of a conflict with insurance company with regards to my claims?

The Grievance Redressal Cell of the Insurance Regulatory and Development Authority (IRDA) looks into complaints from policyholders. Complaints against Life and Non-life insurers are handled separately. This Cell plays a facilitative role by taking up complaints with the respective insurers.

Policyholders who have complaints against insurers are required to first approach the Grievance/ Customer Complaints Cell of the concerned insurer. If they do not receive a response from insurer(s) within a reasonable period of time or are dissatisfied with the response of the company, they may approach the Grievance Cell of the IRDA.

Private Insurers:
Shri K.Srinivas, Asst. Director,
Insurance Regulatory and Development Authority
Consumer Affairs Department
United India Tower, 9th floor, 3-5-817/818,
Basheerbagh, Hyderabad – 500 029.
E-mail ids: complaints@irda.gov.in

Public Sector Insurers:
Mr.R.Srinivasan, Officer on Special Duty
Insurance Regulatory and Development Authority
Consumer Affairs Department
United India Tower, 9th floor, 3-5-817/818,
Basheerbagh, Hyderabad – 500 029.
E-mail ids: complaints@irda.gov.in . As claims/policy contracts in dispute require adjudication and the IRDA does not carry out any adjudication, insured’s are advised to approach the available quasi-judicial or judicial channels, i.e., the Insurance Ombudsmen, Consumer for or the Civil courts for such complaints.

The list of Insurance Ombudsmen along with their contact details are available on this website under the heading ‘Ombudsmen

Here is the link

If you have a good broker from whom you have purchased the policy, then they will help you in coordinating with health insurance companies. Coverfox is one such health insurance broker and our health insurance partner from whom you can buy the policy.

Just leave your details on this link and they will help you with personal support.

14. What is the difference between Critical illness insurance and normal health insurance ?

In a critical illness policy you are covered for certain mentioned critical illnesses only. Some of coverage’s are Kidney disease, brain tumor, and major organ transplant and many more depending on the companies.

If you have normal health insurance you will definitely get covered for critical illness but in critical illness you won’t get coverage for normal disease like malaria, typhoid.

For example: If your age is 25 and you buy normal health insurance from any XYZ company and let say its premium is Rs.3000 for cover of 3 lacs but if you buy critical illness policy for 3 lacs the premium would be less because considering your age the changes of you getting a critical illness is lesser than any normal disease.

Similarly for old age person the premium for critical illness insurance will be more than normal health insurance because chances of getting that critical disease are more at older age. One other option would be to avail critical illness rider in term plan itself.

15. What is the benefit of critical illness policy?

So as you grow older it is advisable to have another critical illness policy along with normal health insurance. So those at old age when undergo major operation or transplant, this critical illness policy can be used and for minor disease normal health insurance is used.

benefits of critical illness insurance in India

Image source: Slideshare.net

The reason for this is e.g. if you have normal health insurance of 5 lacs and you undergo tumor surgery with other complications and the expenses are around 4 lacs and after sometime you get hospitalized because of ill-health then you have nothing left in your health insurance.

16. What is Domiciliary Hospitalization?

Domiciliary Hospitalization means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely:

i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or

ii) The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein

For smooth claim process, just take care that all your documents are in place and to be on a safer side have a report from your family doctor, stating that this person cannot move to nursing home/hospital due to such and such reasons.

It just provides the proof and makes the process simpler. Note that every company does not offer this facility, you should check your policy document.

17. Some important exclusion under health insurance policy.

1 Pre-existing diseases i.e. Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company.

Pre-existing diseases will be covered after a maximum of four years since the inception of the policy

2. Any disease contracted during the first 30 days of inception of policy except in case of injury arising out of accident

3. Certain diseases such as cataract, piles, hernia, and sinusitis etc. are excluded for specified periods if contracted or manifested during the currency of the policy.

4. Injury or Diseases directly or indirectly attributable to War, Invasion, Act of Foreign Enemy, War like operations.

5. Cosmetic, aesthetic treatment unless arising out of accident.

6. Cost of spectacles, contact lenses and hearing aids

7. Dental treatment or surgery of any kind unless requiring hospitalization

8. Charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations, without any treatment.

9. Naturopathy or other forms of local medication

10. Pregnancy & childbirth related diseases

11. Intentional self-injury / injury under influence of alcohol, drugs

12. Diseases such as HIV or AIDS

13. Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the attending physician.

14. Convalescence, general debility, run-down condition or test cure, congenital external diseases or defects or anomalies, sterility, venereal disease.

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112 replies on this article “17 most important questions that you should know before buying Health Insurance”

  1. Sanjay Singh says:

    I had insurance through TPA when I was working in a corporate. I left the job. Is my insurance still valid for the year?

    1. No, it was a group cover which was valid if you are with company

  2. Rishav says:

    Can a person get claim from his and spouse’s mediclaim, in case both are employed in the same company?
    Also on the first place can we add Spouse as a dependent if he or she works in the same company?

  3. KETAN says:

    I HAD MEDICLAIM POLICY FROM LAST TWO YEARS RECENTLY I ADD MY DAUGHTER NAME WHO IS ONE YEARS OLD AFTER ADDING HER NAME AFTER 7 DAYS SHE IS HOSPATILIZED DUE TO PHENOMONIA FOR 5 DAYS SO CAN I GET MEDICLAIM

  4. Paras says:

    Hello
    I have medical insurance coverage for me and my wife given by the company where i work.
    My wife has recently got hospitalised and i want to make insurance claim, my wife name is M KIRTI but on all the medical bills, hospitals bills and medical reports is written M KEERTHI will it make any problem during claim .
    Please provide your suggestions and solutions.
    Thanks in advance.

    Regards,
    Paras

    1. Hmm.. we cant be sure on that. The name written on bills should match with the documents name with health insurance company. Please check that!

  5. Sangeetha says:

    Hello,
    I seem to have a problem and wondering if you can advice. I recently purchased a health insurance policy after talking with the agent and after confirmation that my policy proposal was accepted. I made the payment and I was informed I would receive a soft copy of the policy in 24hrs. When it did not come through I called them up and they said wait for another day. I contacted their customer service and sales team and now it has been 5days. I am again just asked to wait for 24hrs! I have a payment confirmation and reference number but not a policy number.
    My question: Is it normal for the company to take so much time? What can I as a customer do now, because they have my money but don”t issue me policy neither explain what is going on. How long should I wait and what can I do about this?

    Thank you

    1. You never get the policy instantly ! .. It will be going for underwriting process and then medicals and all will be done, only then the policy will be accepted.

      Which company is it ?

      1. Sangeetha says:

        soft copy of policy arrived about a week and half later!
        It is not common knowledge that you ‘never’ get it instantly. I blame the customer service/sales executives who promise to deliver within the time frame set by themselves. They did not fulfil their commitment and also did not respond to my queries which is all bad business and unprofessional.

        1. Yea if they had promised it instantly, then its a wrong thing on their part

  6. Madhu says:

    I have a doubt. Please clarify me.. Whether sister can show or add as a spouse in health insurance? If so we can add what are all the documents should be submitted?

    1. Yes, a lady can add her husband in the policy

  7. Yogita says:

    Dear Mr. Chopra,

    My father-in-law was admitted to a hospital with acute abdominal pain. For diagnosis the cause, colonoscopy was performed amounting to Rs.35,000/-. No abnormality was observed during the procedure. After 1-2 days, skin lesion were seen on his abdomen and he was diagnosed to be suffering from Herpes Zoster. He was discharged after 1 day post diagnosis. Our TPA has rejected the claim for colonoscopy. Is the TPA correct in rejecting the claim?

    1. Its simply depends on the policy document, see if its covered or not !

  8. Salil says:

    My Wife and me have corporate health plans with the same TPA (different insurers).
    We want to split the maternity costs between the our policies via reimbursement (not cashless)

    When approaching the TPA, we were informed that splitting the reimbursement over multiple policies is not possible. They say, as per IRDA mandate, for splitting, one claim should be cashless, and the other should be reimbursement. Does this sound right? My hospital did not provide a cashless option.

    1. I am not aware on this .

  9. Nilesh Agarwal says:

    I have a policy for 2 lacs and i want to increase the sum insured to 3 lacs, but the company is not allowing because we made a claim in 2013. they are saying after making a claim you cannot increase your policy till two years that too if u have not made any claim.

    1. IT would depend on them only . Its their rule .

  10. Ayaz says:

    Hi

    Me and my brother work in same company.
    1) Is there any IRDA norm that we can’t add our parents name as dependent names in both corporate policies since both of us has group medical insurance from our company? Note that my company is paying 2 premium amounts independently for both of us.
    2) Can TPA put such rules that one person can’t be covered in 2 policies?
    3) is there any IRDA norm that both parents have to be insured under one medical policy only? If point 1 is not feasible, can we select to insure father & mother separately under the 2 policies? Can TPA take a call not to do this as per their rules?

    Pl assist to share any link where I can get some IRDA guidelines around this if available.

    Thanks a lot in advance!!!

  11. Adinarayana says:

    Sir,Recently I was oparated for mitral volve replacement under Employees Health scheme with cashless.But I am a policyholder of LIC in healthplus scheme from 7 years.can I claim in LIC.Please clarify.

    1. Is it covered under the policy ?

  12. Koushik Paul says:

    I work in an educational institution as a faculty. As an employee, my spouse and myself have heath cards where my name and ID are written, while policyholder’s name is written as that of my institution. The card have both the insurance company and TPA’s name embossed on it. My wife recently underwent a surgery in a hospital and I claimed for reimbursement through our Institute. However, it is almost 2 months, and I am yet to receive the reimbursement. Both the TPA and insurance company avoids a direct reply and are non-committal about any time-frame. Can I as an individual approach the Ombudsman or complain to IRDA?

    1. Its a group cover .

      You can surely check with TPA and ask for exact status and then reach to IRDA on this

      Manish

      1. Koushik says:

        Thanks, Mr. Chauhan

  13. Pradnya says:

    I have a group medical policy from my employer for Rs 5 lac and have taken another policy from different insurance company for Rs. 3 lac. I have to undergo surgery which costs around 2 lac but the room rent is Rs. 7800 hence cannot be covered under single policy (there 1% cap on room rent in both policies). Can I claim proportionate amount under both the policies so that i can get entire amount reimbursed ? If yes whats the process for it? Can both be made cashless ?

    1. No Pradnya

      Don’t do that. It will be a big mistake. Follow this article and you will realise why I am saying that – https://www.jagoinvestor.com/2015/02/buy-health-insurance-in-india.html

      Manish

  14. Prabir says:

    Me and my brother having the same mediclaim policy. Me and him both have included parents. Now my father is in hospital. can we both claim for the same bill.

    1. Yes, you both should be able to do that !

  15. Deepa says:

    Hi Manish,
    My company insurance covers maternity insurance of 50K and my husband’s insurance company also covers 50K. My medical expenses is estimated to be around 1L or more. Is it possible for both of us to claim 50K each?

    Please advice. thank you

    1. Yes, that should be possible ..

      1. Niveidta says:

        But how can both claim Manish? Original documents are taken by the 1st insurance company and not returned to you.

        Please elaborate. As far as I know, one cannot claim mediclaim from both the companies for one instance of hospitalization expenses.

        1. No Niveidta

          It does not work like that. You can claim from two companies, The way it works is like this

          1. You first submit the original documents to first company
          2. First company gives you a letter that they have original docs and they will give their stamp etc on the xerox
          3. 2nd company will accept it, because thats the standard thing in the industry !

          Manish

  16. Komal says:

    Dear Sir,

    Currently i have a health insurance plan of SBBJ medikawach which has a tie up with National Insurance company. I have this policy for last 3 years i.e started in Dec 2011 and is due for renewal in Dec 2014. The medical cover is Rs. 3 lacs with a premium of around Rs. 4700.
    I recently got a letter from National Insurance company that they have terminated the tieup with SBBJ and in order to continue they have introduced Parivar mediclaim policy. But the irony is for the same cover they have increased the premium from Rs. 4700 to Rs. 11000. (two & a half times)
    Is it justified?
    I am concerned because the policy is in its 4th year & I don’t want to start afresh with any other bank.
    I came to know that Bank of Baroda, Bank of india also have tieup with National Insurance Co. & they are offering similar policy at premium of around Rs. 4700 for a medical cover of Rs. 3 lacs.
    My question is that whether I can transfer this policy to BOI or BOB and avail the benefit of the policy which have been accrued over the last 3 years. National Insurance co. is asking for Rs. 11000 for renewing the same policy, directly by them. I am looking forward to your valuable advise as the policy is due for renewal next month & I don’t want to lose the benefits of the previous policy.

    Thanking you

    1. These are the issues with the tie-up version of health plans . Better go directly with the company itself and not via bank , Let me know if you want help in this regard ?

      Manish

  17. Chaitu says:

    Hi,

    My wife and me works in same organization and we are covered under same group policy. Now if any one is ill and hospitilation bill is huge can we avail reimbursment or cashless from both our medical covers?

    Please speciy same in matter of Meternity also….

    1. Yes, That should be possible I guess !

  18. Tejas says:

    Recently my mom was hospitalised for normal viral infection and was dischargd in 3 days the bill being of 36k, we have critical illness policy of tata aig which only gave me 6600…am looking for policy which will cover entire hospitalisation…premium 50k is fine.

    1. Sure . I think we can connect you to right people who will help you explore the best options

      Manish

  19. Kamlesh patel says:

    Hi Mahaveer & Manish,

    my mother is admitted in hospital for 15 days.i submitted all Indore case paper and also nursing chart of 15 days and also all related papers but company replied us to we are sorry to inform you that Stay in Hospital justified for only 5 days so rest of Room rent not payable .so what i do for that to my 10 day money back.

    Please giving me advise what i do my next step.?

    1. Its all about terms and condition , Is company doing whatever is mentioned in terms or conditions or not !

      1. Kamlesh patel says:

        NO, in term and condition there is not this type of thing , they also not giving any clarification for how 5 days justify and why other is not payable.

        1. In that case if its not there in terms and conditions section , then company cant ask for you that.

  20. padhma says:

    i want to know how health insurance payments are made?
    i.e should we first pay by our own money at the hospital and then claim the insurance or is there a way where insurance company pays directly to the hospital?

    1. 1st option is always there in any policy . Payment by health insurance directly to health insurance company is called “Cash less” . its only possible with the network of hospitals

  21. ranjith says:

    im having back pain from some time so im thinking of visiting a doctor and as far as i know in almost all cases they do tell us to do x ray, MRI etc and then they start their treatment….i want to know if my insurance company will pay for treatment, xray, mri etc and all other things or they pay only for treatment

    1. They will pay for everything

  22. Kaushal Gupta says:

    Hi All,

    Please guide me….Me and my wife both are working and have Group insurance from our respective organization which include Maternity benefit cover for 50k each.

    We are visiting Cradle – Appolo clinic which is not covered for cashless by any of our TPA. What is the correct procedure to get the reimbursement and who should claim first as we are expecting our bill from Cradle to be somewhere 80k.

    Can we do it like any one of us submit the original document to his/her TPA and attested photocopy to other TPA for remaining amount exceeding 50k.

    Please help. Waiting for reply

    Thanks in advance.

    Regards,
    Kaushal

    1. Congratulations Kaushal,

      1. Intimate both the TPAs in advance.
      2. You will have to claim reimbursement from any one of the TPAs
      3. Once your claim is settled in TPA 1, get the remaining settled from TPA 2.
      4. Submit the claim settlement summary, policy copy of Policy 1 with Claim 2.
      5. Intimate the other TPA by email with a copy to your Insurance administrator in the company, that since you are claiming first from another policy, there will be a delay in submitting the documents
      6. Please look at the eligibility of room rent in both the policies. Go first for the policy which has higher room rent eligibility.
      7. Check if there is co-pay for “package” billing, in any of the policies. Go for the policy which does not have such billing.

      Hope this will help.

      With good luck and wishes,

      Mahavir Chopra

      1. vamsi says:

        Hi Mahaveer & Manish,

        I have a query related to the same question of kaushal.
        If both the TPA’s of myself and my wife organizations are providing cashless and reimbursement facilities, how should i proceed.
        Considering that my wife has more eligibility amount for maternity expenses than my company TPA, if we go for cashless from my wife company TPA can we reimburse the remaining amount through my company TPA?
        Kindly suggest.
        Also as per your suggestion to inform both TPA’s in advance, should i keep both the TPA’s in the same mail and inform on how we want to proceed ahead ?

        Regards,
        Vamsi

        1. Hello Vamsi,

          – Is the estimated cost of hospitalization more than the maternity capping in any of the 2 employer policy covers you hold? If the cost is lesser, than you can choose one of the 2 which has a better limit/cappings and limits on room rent etc.
          – If the estimated cost is more, then claim in cashless for the better policy and remaining through reimbursement.
          – Intimate claims in separate emails or same email will have no impact.

          1. vamsi says:

            Dear Mahavir,

            Thank you for your response.
            Yes, the estimated cost is comming more than the maternity capping/limit provided in both the TPA’s.
            As suggested by you, i will proceed with the TPA whose capping is more for cashless and remaining will claim in another TPA as reimbursement.

            One additional question, do i need to request the hospital to provide seperate bills to have both cashless and reimbursement ? or i can use the remaining bills which are above the cashless for reimbursement.

            Regards,
            Vamsi

            1. Hello Vamsi,

              You can submit the remaining bills, with the claim settlement summary. You need to submit the attested photocopy bills of the ones you have claimed in the first cashless claim.

            2. vamsi says:

              Hi Mahavir,

              Thank you for your response and appreciate your support to the people like us answering our queries.

              Regards,
              Vamsi

  23. jagannath thakur says:

    What happens when a patient claims for his bills from two different mediclaim policies at the same time, submitting the originals to one and the photocopies to the another insurance provider. If one gets the approval first, will the second mediclaim automatically reject – or the patient has to tell the second insurer that – please dont proceed as I have been paid

    1. You cant get the claim from two companies for the same thing , its not like life insurance, they would need original documents .

      1. jagannaththakur says:

        Yes, thanks for the reply.

  24. sangeetha says:

    Hi,

    If an insured is having two mediclaim policy for a sum insured of Rs.3lacs each. And if the insured is hospitalised and claim amounts to Rs.4 lacs. Here in both the policies the room rent is restricted to 1% of sum insured and actual room rent per day amounts to Rs.5000/- . Whether the insured can claim under first policy where room rent of Rs.3000 will be payable and balance of Rs.2000 in second policy.

    Pls confirm.

    1. yes that should be possible

  25. Praseena says:

    Hi,

    I have a mediclaim policy from National Insurance. But I m not satisfied with my TPA. Is it possible to change the TPA while keeping the same policy?

    1. I dont think so , TPA is choosen by Insurer , If they change it , only then it will change, its not upto the customer

      1. Praseena says:

        So is it possible for me to request the insurance provider to change my TPA?

        1. No, One company has one one TPA and its not changed for each customer

          1. Praseena says:

            Ok… Thanks a lot for your quick response.. Really Appreciate..

  26. Deepak says:

    I and my sister have health insurance from our respective companies. In my case the copay is 20% whereas in my sisters case the copay is 10%.

    now if my mother is hopitalised for treatment under my medical insurance, the insurance company pays 80% and i pay 20% (co pay), can my sister claim this 20% that I have paid from my pocket from her medical insurance?

    1. Is your mother covered under both the companies . i dont think that your sister can claim it like that

  27. sunny says:

    Hi manish,

    One question. I am planning to take a health insurance policy for my family(individual). For my wife, will the company cover existing pregnancy conditions. My wife is in her 2nd month of pregnancy. Will the company cover delivery and other cost

    thanks in advance

    sunny

    1. Sunny

      The easiest way of answering this question is to ask you .. If you are a health insurance company , will you cover someone for a premium of 10k , when you know that in next few months company will have to pay 70-80k ? Will you ? Does it make any business sense ?

      Manish

      1. sunny says:

        hmm…it does not make any business sense…

        I read couple of your articles and it helped me a lot.

        keep writing…

  28. C V Easwaran says:

    Manish
    I am 63 and my wife is 58 yrs and if we are financially ‘healthy’, would you still advise a health insurance. I have an offer for a floater policy of 5 lacs for both of us at around Rs.35000 p.a. premium. We don’t have any at present.

    1. CV Easwar

      Why not , The reason why you are not looking at health insurance is that you look at it as “Health Insurance” , its not health isurance , its your WEALTH insurance . If you dont take health insurance, then you will loose wealth at some situations , if you are ready for it , then you dont need to take it

      Manish

  29. Rahul says:

    Hello Mahvir Ji,

    Me & my wife both are working.I want to take Health Insurance for myself & my wife. Please suggest me if i should go for Individual or Family Floater.My dilemma is that as per some websites & in TV programs also, Individual is better.As per these programs, if senior most person dies or reaches the maximum age of renewal of policy , whole policy get lapse and other members has to take new policy with fresh exclusion period & pre-existing disese not getting covered.
    How much true is this? As as per some policy persons from Apollo & star, next senior most person get covered automatically with individual plan with existing exclusion period and pre-existing disese period but this thing is not mentioned in their brochure any where.

    Also,I want to cover my retired Father( 55), Mother(52) & Younger Brother(21) under health Insurance. I have selected two different options. Please suggest which one will be better.
    1. Should i take 6Lacs FF from Oriental on my name covering myself ,father,mother & 3 lacs Apollo Munich FF on my wife name covering her & me.So that we both ( me & my wife) and our family get good cover along with tax benefits.

    2. We both take Apollo Munich Individual plan for me & my wife.

    Please suggest me as i want to invest money in medical policy which should be benefits to us when it is exactly required.

    I will be very thankful to you.

    Regards,
    Rahul

  30. Rahul says:

    Hi Manish,

    I want to take Health Insurance for myself & my wife.
    Biggest Question is – whether i should go for Individual or Family Floater.
    I will take what will be beneficial till long run for us.
    My dilemma is that as per some websites & TV programs, Individual is better.As per these programs, if senior most person dies , whole policy get lapse and other member has to take new policy with fresh exclusion period & pre-existing disese not getting covered.
    How much true is this? As as per some policy persons from Apollo & star- next senior most person get covered automatically with individual plan with existing exclusion period and pre-existing disese period.

    Kindly suggest.

    Also,I want good health Insurance cover for my retired Father( 55), Mother(52) & Younger Brother(21). My working mother retiring in 2018 has taken Health Insur from National Insur (FF) for 3 lacs in Jan,11 with Premium is 12K per year.But recently one health insurance agent told me that this plan is not good and one member can’t claim more than 1.5 lacs & offered me that i should take 6 lacs FF from Oriental on my name with covering my mother & father & 3 lacs apollo munich on my wife name to cover wife & myself. So that we both ( me & my wife) get good cover along with tax benefits , which as per him i more necessary for us then to my mother who is retiring in 2018.

    Is it correct. I know you yourself not recommend any health insurance product,but Please help me by giving right suggestion as i am totally confused from last 1.5 months and not able to finalize ?

    We are open to take either FF or Individual but due to so much confusion we are not able to finalize. However, i have shortlisted Apollo Munich for same. Please suggest how is the apollo service record.

  31. raj says:

    1. I understand that a health policy taken through a Bank is a Group Health policy? Then what happens if the contract between Bank & Insurance company terminates?
    (a) The pee-existing cover is transferred i.e. is taken to One’s next Policy from same insurance company? OR
    (b) Loose all the benefits incurred till that date & Start afresh.

    2. Is it possible, there could be difference in coverage aspects between policies taken from same Insurance Company through an Agent or BANK AS AN AGENT?

    3. What about portability differences of these health policies? (Same insurance company but one purchased through an Agent & other through a Bank (as an agent))

    4. Why such a huge difference between premium of Policy taken through an agent VERSUS Policy taken from BANK (as an agent) from same insurance company?

    Regards and thanks

  32. Dhawal Sharma says:

    @RAJIV/MANISH – These all issues happen because of policy wordings or insurar’s TERMs and CONDITIONs which are quite numerous and strict in case of GROUP INSURANCE (Insurance provided by the employer company)..And most of the time (In fact all the time) employees never get the policy wording or they themselves never go through the terms and conditions of the policy..If Rajiv’s company provided insurar says that such a condition was there in the policy that this claim cannot be shared (Only be provided by one company) then Rajiv has no option but to silently bear it..

    Moreover, let this be very clear that PREGNANCY is not an AILMENT or ILLNESS..So i too agree with the last line MATERNITY claim is different from other GENERAL INSURANCE CLAIMs..Its in fact a benefit provided by some MEDICLAIM COMPANIES seperately..

    1. Dhawal

      Thanks for the answer . So pregnancy is such one thing which is not shared generally , are there any others ?

      Also i agree that its not something company came up with suddenly , its just a rule which was always there 🙂

      Manish

  33. Rajiv says:

    Hi Manish,

    Recently I submitted a maternity claim to my company. The total hospitalization charge was Rs 71000.
    My wife had a separate insurance policy provided by her company, through that she claimed Rs 50000, for the remaining amount Rs 21000/, I submitted a claim to my insurance. They rejected it saying that “”The benefit for maternity is considered as “single claim” and it is up to the discretion of the employee to choose the insurance company to make a claim. Also, the below statement (I’ve had shared your Q1 answer) form the employee is valid in terms of general medical claim for any other aliment except maternity benefit.””

    Is it true? Can I so soemthing here? Pls help

    1. Rajiv

      Not sure on this , let Dhawal answer this !. I will bring him

      Manish

  34. Tariq Jagmag says:

    How does one go about claiming two mediclaims if each company asks for original reports and other medical documents?

    1. Tariq

      It does not happen like that , the second company will have to rely on the xerox or the declarations from the first company , for more you can ask at our helpline : https://www.jagoinvestor.com/forum/

      Manish

  35. amarjit kurmi says:

    hey. manish bro..
    what is whole life insurance plan??
    does it as good as term plan.

    1. Amarjit

      Whole life plans are the plans which cover you for whole life ,so when you die it pays your dependents money , the max however is around 90-100 yrs .

      Incase you have questions like this , the whole community can help you in understanding these things better , register and ask questions at our forum : https://www.jagoinvestor.com/forum/

      Manish

  36. Hi Manish,

    This blog entry is really good. It encompasses all the questions one might have about health insurance. The point made about keeping documents up to date for the TPAs is very relevant.
    Future Generali has now started an in-house cell called the Future Generali Health cell (FGH) that process cashless mediclaims directly from the consumers without bringing the TPAs into the loop. This will definitely improve the claim process and make it a lot hassle free.

    Keep up the good work!

    1. Future Generali

      Thanks for your comment , good to see that companies are reading more about customers experience on blogs 🙂 .

      Manish

      1. amarjit kurmi says:

        the nagarik suraksha yojana is gr8 manish bro……
        i m onto it now..

        1. Nice .. go for it

          Manish

    2. Suryaneel says:

      Even MAX BUPA also has their own cell for processing their claims without bringing TPA in the loop

  37. Chandra says:

    @34 what is the best policy available in the market and how much coverage should one take?I need advice on this?

    It is wiser to take a personal Health insurance then depending on the one provied by the employer.

    1. Chandra

      It depends how much cover you already have , if you have just 1 lac of cover from employer than its you who have to answer is it enough ? Are you ready for a situation when hospital costs are like 3-4 lacs ?

      You can search for policies at apnainsurance.com

      Manish

  38. Mayank says:

    Nice Article covering important aspects, useful for everyone!
    Health Insurance is even more important that Life insurance, since when you are dead, you are gone along with your own liabilities, but under permanent disablement comditions, you not only have to provide for your family but for your medicale expenses too.

    Its imprtant that we spread this message of the importance of health insurance and help our friends take this vital coverage.

    Cheers,
    MS

    1. herge says:

      “when you are dead, you are gone along with your own liabilities”

      If this is true critically ill people can take home loans! 🙂

      1. Herge

        And you thought Bankers dont know how to do business 🙂 , try doing it and you will come to know who is more smart 🙂

        Manish

    2. Mayank

      Thanks for your support 🙂

  39. Hemant B says:

    Hi Manish

    According to my understanding, In first point claim shall be divided 90000 each.

    Only in case of top up kind of situation it can be 1 & .8.

    1. Hemant

      The answers are provided by Health Insurance expert .. I think its right , but let them comment again to clarify this

      Manish

    2. Your example is correct. But top-up policy by all insurance companies are available after 3 lacs of normal health insurance coverage.

  40. Manickkam says:

    Loading Charges:

    Is there a way for the company to say NO on how they come to that particular Loading charge for a particular person? Also, Can any company put a loading charge for a healthy person?

    1. Manickkam

      I am not sure if they tell you the procedure before hand , they mention the charges in policy document and if you sign it and take it , you accept what they provide .

      Loading can be put for healthy person also , its not just on claim , but some times its on ratio of claims also and there are other ways of applying loading

      Manish

    2. Company generally doesn’t put loading charges to a healthy person.
      Every company have their own set of rules for denial of insurance.If they feel it is too risky to give a particular person insurance they may reject it

  41. pattu says:

    * Please include procedure for claiming reimbursement from two health insurers

    * Nice points!
    7. Is it better to take accidental policy separately or mix it with term insurance as a rider?

    –> For Rs. 1000 extra a stand-alone accidnet policy offers more. In my opinion riders suck!

    9. If there are no loading charges, can premium still change on renewal?
    –> Max Bupa!

    15. Critical illness policy?

    –> A critical illness today can easily take 10 lakhs. So taking such
    a cover assuming critical illness at old age makes little sense because inflation would deflate the sum.
    Best to have a SIP for old age illness along side CI policy.

    Nice article. Thank you.

    1. Pattu

      I think the procedure to claim from both insurer is same like its with one , you claim it with first and then redo the same thing with 2nd ?

      Manish

      1. pattu says:

        I am talking about two individual mediclaims. When we need to claim a reimbursement how do we go about with giving bills doctor certificates etc. The hospital would give only one original.

        Also how does cashless with two mediclaims work?

        This is also important for CI policies. Suppose one finds about the critical illness during a hospitalization then documents have to be sent to health insurer and life insurer for the CI policy. How does one go about this.

        In LICs health plus policy its clearly mentioned that only photocopies of bills are necesary

        1. Pattu

          Not sure of the procedure myself , may be dhawal or Kashyap can help !

          Manish

          1. Pradeep Borah says:

            Here is the scenario, I have got a company provided health insurance of SA 2L and my spouse has got company provided health insurance of SA 3L. Both health insurance covers max 50K for maternity. The cost of C-section is around 70K-90K depends on hospital. I have taken a cashless claim of Rs 50K from my policy and paid the difference though my credit card and the remaining amount (the paid amount) was reimbursed from spouse’s health insurance. For reimbursement you need to produce original bills and discharge summary which will be returned back by TPA.

            At one of the instance I got “approved” cashless claim from two TPA, however only one can be utilised by the hospital.

      2. sachin says:

        u can,t do this bcoz both of them will ask originals; discharge summary etc.

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