Health Insurance means an insurance taken to cover the cost of medical and surgical expenses.

The cost of medical expenses is high and increasing. A health insurance provides protection against expenses arising due to unexpected medical emergency and ensures that the insured does not have to dip into his savings, break investments or borrow to fund the cost. Health insurance is thus also a very cost effective way to protect one’s finances.

While there is no straight formula to calculate the sum assured for a health policy. There are however certain factors to be considered before deciding the amount.

  • Age
  • Current health condition
  • Occupation
  • City of residence
  • Hospital for treatment
  • Family History
  • Affordability

Buying health insurance at a young age has its own advantages.

  • Lower Premium
  • Easy to get Insurance
  • Overcome waiting period easily
  • Financial discipline
  • Benefit of Bonus

The three important riders one could opt along with basic health insurance plans are.

  • Critical illness rider
  • Personal accident plan
  • Hospital Daily Cash

Waiting period is the number of days a policyholder has to wait before he could avail the benefits of the policy.

Waiting periods include:

  • The initial waiting period
  • Pre-existing disease
  • Disease specific waiting period
  • Maternity Benefits waiting Period

Reasons for rejection of health insurance claim.

  • Waiting Period
  • Permanent exclusion
  • Claim on lapsed policy
  • Misrepresentation or non-disclosure of facts
  • Incorrect claim process
 
  • Make sure you go through the terms & conditions, list of exclusions, waiting period, deductibles if any and the claim process thoroughly.
  • Fill the policy application yourself, take the help of the insurance agent in case of any query or doubt. The insurance agent might not know your medical history completely and fill incorrect information in the application form. At the time of claim settlement, if the insurer finds a discrepancy in the details provided, the claim will be rejected.
  • Make sure to renew your policy and is not allowed to lapse. Claim made on lapsed policy is not accepted.
  • Do not delay informing the insurer about hospitalisation. The insurer has to be informed within 24 to 48 hours of hospitalisation. Delay might lead to rejection of claim.
  • Submit claim settlement request before 30 days from the day of hospitalisation.
  • Before submitting, check and re-check the claim settlement form for accuracy.
  • Take photo-copies of all the forms and documents submitted for claim settlement for future reference.
  • As a proactive measure, keep the insurance card, claim form with the process and the customer care number of the insurance company handy and share it will one or two family members.

All is not lost if the claim is rejected, provided you are able to convince the insurance company that the claim made by you is genuine.

But for that you need to know the reason why the claim was rejected, once you know the reason corrective action could be taken.
 
  • If the claim is rejected because of incomplete information then email the insurance company correct and complete information.
  • In case of incomplete documents, send the complete set of documents to the insurance company via email, fax or courier as required.
  • If the claim is rejected because the medical treatment is not covered by the policy then the onus of proving otherwise lies with the policy holder. Go through the policy document carefully, highlight the clause in the policy document which proves your point and also submit necessary documents if required.
  • Make sure you submit your reply within the time period stipulated by the insurance company, also keep a record of all the communication with the insurance company.
Under section 80D of Income Tax, the purchaser of health insurance, who has purchased health insurance by any payment mode other than by paying cash can avail an annual deduction of Rs. 25,000 from his taxable income for payment of health insurance premium for self, spouse and dependent children. In case one of the member is above the age of 60, then the total deduction will be Rs. 50,000.
For health insurance paid for parents below 60 years, the deduction amount is Rs 25,000. If, one of the parents is over the age of 60, in such as case the deduction amount is Rs 50,000.
The deduction claimed for health insurance premium paid for parents is in addition to the deduction claimed for premium paid towards health insurance of self, spouse and children.
The factors that affect your health insurance premium are
 
  • Age
  • Pre-existing medical history
  • Family medical history
  • Body Mass index (BMI)
  • Tobacco consumption
  • Gender
  • Profession
  • Marital Status
  • Previously uninsured
  • Staying location

Before buying a health insurance policy it is very important you read the prospectus carefully to understand the diseases or medical procedures not covered by the policy.

Generally a health insurance policy does not cover:

  • Pre-existing disease
  • New or advanced medical treatment or procedures
  • Alternative therapies
  • Cosmetic treatment
  • Diagnostic expenses
  • Pregnancy and Child-birth
  • Dental
  • Hearing and Vision
  • Treatment of AIDS
  • Permanent Exclusions

A 15 days grace period is provided to renew the policy after the expiry date. The policy will lapse if the policy is not renewed within the grace period. No cover will be provided during the grace period till the time premium is paid.

Any number of claims are allowed during the policy year unless there is a specific cap mentioned in the policy.

Portability was introduced by IRDA in 2011. In the past in health insurance policies, when the policyholder changed health insurance policy from one insurance company to another, this resulted in losing benefits like ‘waiting period’ for covering pre-existing diseases. With portability, the new insurer i.e. the new insurance company “shall allow for credit gained by the policyholder for pre-existing conditions in terms of waiting period”.

For example, Ravi had taken health insurance policy from company ‘A’. The waiting period for pre-existing disease in the policy was 4 years. After completing 3 years with the policy, Ravi decided to shift to another new health insurance policy with company ‘B’ due to an increase in premium. The waiting period for pre-existing disease with new policy with the company ‘B’ was also 4 years. Prior to 2011 before portability, if Ravi had shifted the policy the waiting period of 4 years with the new policy would have become applicable to him. After introduction of portability the waiting period for pre-existing disease with the new policy will be only 1 year. So, due to portability he did not lose the waiting period benefit.

Procedure for Portability: Write to your existing insurance company specifying the new insurance company you want to shift the policy. Also give a portability application to your new insurer. Both the applications have to be made 45 days before renewal of your existing policy is due. After receiving your portability application the new insurer will provide you proposal form and portability form. Select the new product, fill the proposal and portability form and submit them to the new insurer.
The new insurer will thereafter obtain medical records and claim history from your existing insurer. The existing insurance company must share the details within seven working days through a portal developed by IRDA for sharing the data. After receiving the data, the new insurer has to take decision about the proposed policy within 15 days. It it fails to take decision, then it is bound to accept policy porting.
Just because the policyholder has the right of portability, does not mean the insurer is bound to accept every request for portability. IRDA has also given the insurer the right to reject requests for portability. The insurer can reject the proposal if it does not meet its acceptable risk parameters.

The are few important points to know before you decide to port your health insurance policy.

  • Informing about portability
  • Credit of waiting period
  • Credit of no-claim bonus

Any amount above the ported sum insured will be treated as a new policy.

  • Underwriting on current health status
  • Compelling reason to port

The following documents will be required regarding your existing policy.

  • Copy of the last years policy schedules issued by the previous insurer or renewal notices
  • Self-declaration by policyholder regarding no-claims made
  • If claims have been made then additional documents like discharge summary, investigation report, etc, could be required
  • If there is a past medical history, then consultation papers, prescription, investigation, treatment and report copies
     
     

 

 

A family floater health insurance plan is one in which one or more members of the family are covered under one plan. It means in a single plan the individual along with his or her spouse and children are covered. There will be a single annual premium and fixed sum insured.
Advantages of family floater policy
  • Cost effective
  • Addition of new members
  • Larger sum insured

    Drawbacks of Family floater policy

  • Multiple claims in a year
  • Exclusion of other family members
  • Lack of extensive coverage
In case of Network hospital for a planned surgery, approach the hospital before the date of admission. The hospital with send a pre-authorization form to star health Insurance. In the pre-authorization form you will have to provide your contact number. If for some reason, if the form is not completely filled the authorization request may get delayed.
In case of an emergency admission, contact star health insurance with patient’s policy number at 1800 425 2255 / 1800 102 4477 or approach the nearest office of Star Health or e-mail them at support@starhealth.in.
Procedure for Reimbursement of Claim Inform star health insurance within 24 hours of hospitalisation and claim documents have to be submitted within 15 days from the date of discharge.The following documents have to be submitted along with the claim form at the nearest star health insurance branch for reimbursement of claim.
  1. Copy of Health card
  2. Duly filled claim form
  3. Pre admission investigations and Doctor’s consultation papers
  4. Discharge summary from hospital in Original
  5. Investigation reports (e.g. X-ray, scans, blood report, etc.)
  6. Pharmacy invoices supported by respective prescriptions
  7. Case receipts from hospital, chemist
  8. In cases of accidents, Medico Legal Certificate (MLC) and / or FIR
  9. Copy of the KYC documents
  10. NEFT details, Contact number and E-mail ID
Step 1 : Claim Intimation
In case of an emergency hospitalization, call and inform Religare Health Insurance at 1800-200-4488 within 24 hours of patient’s admission. However, if your hospitalization is planned, kindly intimate them 48 hours prior to your admission by calling on the same number or emailing at customerfirst@religarehealthinsurance.com
Step 2 : Initiating the process for Pre-Authorization
A Pre-Authorization form will be available at the hospital’s Insurance/TPA desk.. Please fill the first section of the form by giving your personal details and hand over signed Pre-Authorization form to hospital’s Insurance/TPA desk for them to fill up the balance details. Hospital will fax the completed Pre-Authorization form to Religare Health Insurance at 1800-200-6677.
Step 3 : Processing a request for Pre-Authorization
Religare’s in-house medical team will review the case and documents submitted by hospital. If your request for Pre-Authorization is approved, you and the hospital will be duly informed by Religare. In case of any information deficiency or further information requirement, you and the hospital will be regularly intimated by Religare to ensure resolution of the same at the earliest. If your request for Pre-Authorization is not approved, it only indicates that Religare is not able to process your request basis the requisite information available with Religare at this point of time. In such cases, you may claim for reimbursement of your expenses after discharge from the hospital.
Reimbursement of treatment expenses
Step 1 : Claim Intimation
In case of emergency, call and inform Religare within 24 hours of your admission at the above given contact details. However, if your hospitalization is planned, kindly intimate Religare 48 hours prior to your admission. The following information is to be provided during the claim intimation-
  1. Policy Holder’s Name.
  2. Claimant’s Name & Customer ID.
  3. Hospital details.
  4. Diagnosis and Treatment details.
  5. Approximate claim amount.
  6. Date of admission
Religare will provide a reference ID for all future communication pertaining to the claim request.
Step 2 : Initiating the Claim process (Also applicable for Pre/Post Hospitalization claims)
The completed and duly signed claim form has to be sent to Religare along with the following documents –
  1. Duly completed and signed Claim form, in original
  2. Valid photo-id proof
  3. Medical practitioner’s referral letter advising Hospitalization
  4. Medical practitioner’s prescription advising drugs/diagnostic tests/consultation
  5. Original bills, receipts and Discharge card from the Hospital/Medical Practitioner
  6. Original bills from pharmacy/Chemists
  7. Original pathological/diagnostic tests reports/radiology reports and payment receipts
  8. Indoor case papers
  9. First information Report, final police report, if applicable
  10. Post mortem report, if conducted
  11. Any other document as required by the company to assess the claim
The claim form and additional documents are to be sent to Religare at the following address:
Religare Health Insurance Company Limited, Unit No. 604 – 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001 (Haryana).
Step 3 : Claim Processing and Reimbursement
Religare’s In-house medical team will review the case and documents submitted by you. If your request for reimbursement of expenses is approved, you will be duly intimated by Religare. In case of any information deficiency or further information requirements, you will be communicated instantly to ensure resolution of the same at the earliest. If your request for claims is declined, you will be communicated the same along with valid reason(s) for rejection. However, if the insured/ insured’s representative has further documents to enhance/substantiate his case for claim, the same can also be sent to Religare; and if found rational, the case will be reopened for review of the documents and response, if any.
Network Hospital
In case of emergency hospitalisation
Inform Apollo Munich at 1800-102-0333 or fax at 1800-425-4077 within 24 hours of hospitalisation with the policy number of the patient.
In case of planned hospitalisation
Inform Apollo Munich 48 hours prior to the hospitalisation for seeking cashless authorisation. Apollo Munich could be contacted or faxed at the above given contact details.
Reimbursement
Please send the claim form with the documents mentioned in the claim form to Apollo Munich within 15 days from the date of discharge at the below given address. In case there is a deficiency in the documents or information provided, Apollo Munich will send the deficiency letter within 7 days of receipt of claim documents.
On receipt of the complete set of claim documents the admissible amount will be paid within 30 days.
Address Claims Department, Apollo Munich Health Insurance Co. Ltd, Ground floor, Srinilaya – Cyber Spazio Suite # 101, 102, 109 & 110, Ground floor, Road No. 2, Banjara Hills, Hyderabad – 500 034
or
Claims Department, Apollo Munich Health Insurance Co. Ltd, Central Processing Center, 2nd and 3rd floor, iLABS Centre, Plot No. 404-405, Udyog Vihar, Phase -III, Gurgaon – 122016 Haryana

About Happoos

We love our families and want to do the best for them. The decisions we make and the actions we take have the needs and the interest of the family at its core. One of the best decisions you can take for your family is to invest in a health insurance policy.