Health Insurance in India
Health insurance can be defined as insurance against the future medical expenditure of a person. This means that when someone takes a health insurance plan he or she expects a certain amount of medical expense to be there in future and that individual is paying for that in the present in the form of premium. The main aim of a health insurance plan is to make sure that people have enough money to take care of their emergency medical requirements when they get old.
However, a health insurance policy does not always cover every possible health problem someone might encounter in the future. There are certain terms and conditions agreed to by the insured (person who is taking the plan), and the insurer (entity that is providing the plan) and the entire procedure happens according to what has been agreed to in the contract.
Appropriate time to take health insurance
According to experts the best time to avail a health insurance plan is when the insured is still in a good physical condition. The normal logic among young people is that since they are rarely afflicted by physical ailments they do not need such a plan.
In reality people can fall prey to a disease or other physical problem at any time - nobody can be absolutely sure of a life fully free of such issues. Normally as someone gets older the problems increase and the possibilities of some major disease are always there.
A problem with trying to get a medical insurance during old age is that since there are more chances of a medical condition the premium is often high or the insurer is not ready to cover the individual in question.
Types of Health Insurance
In India there are two major types of health insurance plans - critical illness insurance and medical insurance.
Medical insurance: this form of insurance provides hospitalization cover and pays back medical costs that have been there for paying for diseases or surgery when the insured was admitted in a healthcare facility.
Following are the various forms of medical insurance:
Individual medical insurance
Overseas medical insurance
Group medical insurance
There are certain health policies which pay back the actual expenses of hospitalization for all diseases - these programs are primarily offered by non life insurance providers and are normally referred to as Mediclaim policies. The other health insurance policies are available from both non life and life insurers.
The accidental insurance policies insure a person against the risk of any form of accident. There are certain health insurance providers such as Apollo Munich who provide medical accident insurance facilities as well. Besides, there are several other insurance providers that have accidental insurance policies:
Critical illness insurance: this type of health insurance provides cover against the threat of major ailments. With this program, the insured can be sure that he or she will be receiving a pre determined amount in case the individual is diagnosed with a critical illness that is part of the initial agreement.
With these plans, the payment is done within a few days of the diagnosis and once the payment is done the policy is no longer in operation. Under normal circumstances these plans cover the following:
Aorta graft surgery
Significant organ transplant
Coronary artery bypass surgery
First heart attack
Primary pulmonary arterial hypertension
Ways to file health insurance claims
The following documents are needed in order to register the claims for a health insurance policy:
Properly filled and signed claim form
Reports and receipts of diagnostic tests accompanied by doctor's notes
Discharge certificate of the hospital
Receipts and bills from consultants, anesthetists, or specialists with diagnosis certificate
Illness related documents right from the day it was detected - this includes consultations with the physician and the insured's medical history and
Surgeon or doctor's certificate that states the complete recovery of the insured
Bills, cash memos, and receipts from the healthcare facility - this needs to be backed up with proper prescriptions
Providing previous policies' details to the third party administrator - accidents are regarded as exceptions
If the hospitalization is planned the following procedures need to be followed:
Getting in touch with the 3rd party administrator for the particular policy and providing them the information about hospitalization Making sure that the healthcare facility is in the network - even if the hospital or nursing home is not in the network the money will be provided Verification of coverage terms
Contacting the TPA (third party administrator) regarding the availability of cash less facility
If the hospitalization is not planned the processes mentioned below have to be adhered to:
The TPA has to be informed as early as possible and the claim form has to be collected and filled up properly
The claim form along with necessary documents has to be submitted within 7 days of the insured's recovery
Procure all the treatment related documents from the hospital once treatment is completed
Bills have to be paid by the insured initially - the insurance company will only reimburse them
The policy document has to be read properly to understand which expenses are included
There is a possibility that the claimant may be rejected if the disease is not covered by the plan. In such circumstances the claimant needs to send a letter to the organization within 15 days to file a complaint.
If the payment is incomplete the claimant needs to contact the TPA and find out the reasons for the same. In majority of such cases it has been seen that if additional papers are provided the remainder of the claim is settled. -