Mediclaim Insurance Factors

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Some of the most comprehensive health insurance plans in India are captured in the table below. One has to keep in mind the following factors while opting for a good health insurance plan :
  • Sum Insured, Coverage / Benefits under the Plan
  • Pre / Post Hospitalisation Cover
  • Lifelong Renewability
  • Co Payment by the insured under the plan
  • Insurance Company – Claims Settlement Ratio and Policy terms & condtions
  • Cashless Network of the insurance company / TPA
  • Exclusions and Waiting Periods under the Plan
  • Additional Coverages – Maternity, AYUSH, Organ Donor, Domiciliary Cover etc
Find out the factors to consider when comparing mediclaim insurance in India.

Factors to consider when comparing mediclaim insurance in India

  • Choosing the Right ‘Sum Insured’
    It is important to ensure adequate coverage while buying Indian mediclaim insurance. With every increasing medical treatment costs, having an optimum coverage amount is very important. A person living in a metro city may require a higher sum insured than one residing in a smaller town, an older person should opt to have a higher coverage than a younger person. Also if one is opting for a Family Floater, having sufficient coverage for all members of the family is critical.
  • Cashless Hospital Network of the Insurance Company
    This pertains to the number of hospitals that the insurance company has tied up for cashless treatment, ie. where the insured need not pay the treatment expenses at the time of discharge from hospital. The larger the network of hospitals, the better. Also see if the larger and better known hospitals are covered in the city of the insured’s residence.
  • Waiting Periods
    Waiting Period is the period during which the insurance company is not liable to pay any claims to the insured for specific coverages. Most health insurance plans offer different waiting periods for different covers, one needs to review and compare them before opting for a particular plan.
  • Exclusions Under the policy
    One must go through the detailed list of exclusions before opting for a particular Indian mediclaim insurance plan…these are essentially the benefits/features that are not covered under the chosen policy and the list of exclusions vary from insurer to insurer. Also once the policy is received, kindly go through the terms and conditions since there is a free look period for all policies, during which time the policy can be cancelled if the insured is not happy with the selected plan.
  • Lifetime Renewability
    Renewability means the maximum age till the insured can have their Indian medical insurance policy renewed while continuing to enjoy the same coverage. Most health insurance policies today offer lifelong renewability, but the insured needs to confirm the same prior to opting for a plan. One must understand that buying a policy for the first time at a young age will help in having a lower premium, and one can enjoy accumulated bonus coverage for claim free years, but the policy will normally be required when the insured is at an advanced age.
  • Co-payment Terms
    Co-payment is the insured’s contribution to a particular claim – it is normally a defined percentage of the claim amount payable by the insured while the rest will be settled by the insurance company. For example, if there is 15 % co-payment in a health policy, the insurance company will pay only 85% of the covered expenses and the insured individual will have to bear the remaining 15% of the hospitalisation/treatment charges. It is important to note that lower premium could sometimes mean higher co-payment terms, so the insured needs to be wary of the same while finalising their plan.
  • Claim Settlement TAT / Ratio
    The Claim settlement turnaround time (TAT) and settlement ratio of the insurance company should also be evaluated while finalising the insurance plan and provider. A good insurance company is one with shortest claim settlement TAT and highest claim settlement ratio. Most insurance companies also work with Third Party Administrators (known as TPAs) for claims management, while some manage the claims directly. It is important to know who one has to deal with at the time of a claim.
  • Other Important Clauses
    It is equally important for the insured to evaluate clauses like Day Care procedures (the number of them vary from insurer to insurer), Pre/Post Hospitalisation timelines, Coverage or Pre Existing Conditions, specific Sub Limits for certain coverages are also factors to be considered while finalising on the optimum Indian medical insurance policy.

A copayment or copay is a fixed amount for a covered insurance benefit, paid by a patient to the hospital/provider while receiving the required treatment. It may be defined in an insurance policy and paid by an insured person each time a medical service is accessed. It must be paid before any policy benefit is payable by an insurance company. Copayments do not usually contribute towards any policy out-of-pocket expenses. So, Co-pay is the % of the claims expense that the policyholder will need to pay against each claim. Most senior citizen health plans come with a co-payment ranging from 10% to 30% depending on the treatment availed by the insured. Opting for a higher co pay could also mean a lower premium.

Co payment are normally introduced in insurance plans to ensure small claims for regular/routine treatment like cold/cough etc are not filed by the insured. It also acts a deterrent to the insured going to premium hospitals and seeking unnecessarily high cost treatment since the insured will end up paying their share of the overall expenses. On the flip side, it may also discourage the insured from taking some advanced and costly treatment which may actually be required because they would end up paying their share of the cost.

Insurance Company / Product Name Age / Eligibility Sum Insured Range Unique Features of this plan
Apollo Munich - Optima Restore

Apollo Munich
Coverage is offered from the age of 5 years till maximum entry age of 65 years.

A dependent child can be covered from the 91st day (if either parents are covered under this policy)

Lifelong Renewal
₹ 3 lacs - ₹ 50 lacs
  • The sublimits for patient room and medical expenses is Nil.
  • The New Restore Benefit- Instant addition of 100% basic sum insured to your cover, on your first claim.
  • Multiplier Benefit- Multiplier Benefit Double your sum insured in two consecutive claim free years.
Star Health – Family Health Optima Insurance Plan (Individual & Family)

Star Health
Persons between 18 years and 65 years of age at the time of entry can take this Insurance.

Dependent children can be covered from 16 days and up to 25years of age (upto 3 children)

Lifelong renewals
₹ 3 lacs - ₹ 25 lacs
  • No third Party Administrator, direct in-house claim settlement + Network of more than 9600+ hospitals across India.
  • Additional Sum Insured upto 25% of Sum Insured – Max 5 Lac for Two Wheeler Road Accidents.
  • Automatic Restoration of SI - 3 times at 100% each time, during the policy period + Auto Recharge Option.
HDFC Ergo M: health Suraksha

Entry Age : 91 days .

Children below 5 years would be covered provided both the parents are covered under our policy.

No Maximum Cap on Entry Age

Lifelong Renewal
₹ 3 lacs - ₹ 50 lacs
  • 586 Day Care procedures covered.
  • Sum Insured Rebound - Get additional sum insured equivalent to the admissible claim amount upto a maximum of the basic sum insured.
  • No Room Rent Capping.
Bajaj Allianz Health Guard

Bajaj Allianz
Persons between 18 years and 65 years of age at the time of entry can take this Insurance.

Dependent children can be covered from 3 months and up to 30 years of ag

Lifelong renewals
₹ 1.50 lacs - ₹ 50 lacs
  • Sum Insured Reinstatement - In case sum insured along with the cumulative bonus (if any) has been completely exhausted during the policy year, it will be reinstated
  • In-house claim settlement team that ensures a quick, smooth and easy claim settlement process.
  • Organ Donor Cover - Expenses towards organ donor’s treatment for harvesting of the donated organ are covered under this policy.
Tata AIG Medicare Premier

Tata AIG
Entry Age : 91 days

Children below 5 years would be covered provided both the parents are covered under our policy.

Persons between 18 years and 65 years of age at the time of entry can take this Insurance.

Lifelong Renewal
₹ 5 lacs - ₹ 50 lacs
  • No room rent restrictions in.
  • Global Cover: Insured can be covered for Medical Expenses incurred outside India, upto the sum insured provided that the diagnosis was made in India and the insured travels abroad for treatment.
  • Consumables Benefit available.
Religare Health – Care

Religare Health
Entry Age : 91 days

Persons above 18 years of age at the time of entry can take this Insurance.

No Maximum Entry Age

Lifelong Renewal
₹ 4 lacs - ₹ 40 lacs
  • Annual Health Check up every year if it is a claim free year.
  • DUp to 150% No Claim Bonus with NCB Super.
  • Unique Unlimited Automatic recharge.
  • Care anywhere – Global Cover for 12 Critical Illnesses.
Niva Bupa Health Premia

Any Age Enrolment

Lifelong Renewal
₹ 10 lacs - ₹ 300 lacs
  • Sum Insured upto ₹300 lacs.
  • Indemnification of alternate treatments like Ayurveda, Unani, Siddha and Homeopathy (AYUSH).
  • Medical treatment abroad for 9 selected diseases (platinum plan only).
New India Mediclaim Premier

All the persons proposed for this Insurance should be between the age of 18 years and 65 years.

Children between the age of 3 months and 18 years are covered provided one or both parents are covered concurrently.

Lifelong Renewals.
₹ 1 lacs - ₹ 15 lacs
  • No Zonewise Premium rating – rating only based on age and sum insured + No Loading for Adverse Claims Experience.
  • Lifelong Renewal subject to there not being a break in the renewal of the policy.
  • Pre Acceptance Medical Check up only for insureds beyond 50 years of age.
  • No Loading for Diabetes & Hypertension.
SBI General Arogya Premier

SBI General
Entry Age : 3 months

Maximum Entry Age : 65 years

Lifelong Renewals
₹ 0.50 lacs - ₹ 30 lacs
  • No pre-policy medical test up to the age of 55 years for people with no medical history.
  • Automatic Reinstatement of Sum Insured + Cumulative Bonus of 10% of SI for each claim free year maximum up to 50%.
  • Indemnification of alternate treatments like Ayurveda, Unani, Siddha and Homeopathy (AYUSH).
Royal Sundaram Lifeline

Royal Sundaram
Entry Age : 91 days

Persons above 18 years of age at the time of entry can take this Insurance.

No Maximum Entry Age

Lifelong Renewals
₹ 2 lacs - ₹ 150 lacs
  • Provides coverage for International Treatment for 11 specified illnesses upto Sum Insured along with return airfare upto Rs.3lacs.
  • Access best class healthcare facilities with no capping in terms of Room Rent, disease specific sublimits, etc.
  • OPD Treatment covering the expenses incurred on doctor’s consultation, medicines, diagnostic tests, etc.
ManipalCigna ProHealth

Min Entry Age: Child - 91 days, Adult - 18 years

Max Entry Age: No limit

Cover Type: Individual and Family Floater/

Lifelong Renewal
₹ 2.5 lacs - ₹ 100 lacs
  • Inflation protection guaranteed Cumulative Bonus up to 200% of Sum Insured.
  • Immediate consultation, pharmacy, diagnostic and Medicines up to ₹20,000 (as per plan)
  • More coverage with 100% Restoration of Sum Insured any number of Times.

It may not be entirely factual to state that most health insurance plans in India are ridiculously expensive and unfair. One must realize that since India is today so uninsured (@less than 20% insurance penetration and that too in Urban India with Rural India’s insurance penetration @around 15%), the premiums also need to be shared by this smaller group of insureds and the burden of the insurance claims falls upon a smaller section of India’s population. This results in high premiums for the paying population. We must realize that once more and more individuals get insured under Health insurance, the overall cost of such policies will definitely start falling. The Indian Government has also taken steps to increase health insurance penetration through their Government funded schemes but there is still a long way to go.

By nature, Indians are spontaneous and emotional and rarely go into the specifics and details of anything. The same is true of Health insurance as well. Most insureds do not go through the policy terms and conditions before buying any insurance plan or after having bought the plan to understand what is covered and what is excluded. Making many assumptions, they get to know about the coverage (or lack of coverage) only at the time of a claim. Hence when their claim is denied, they tend to believe that the policy is unfair even though the coverage was the same all along. The IRDAI is now taking steps to standardize coverages and terms across all insurance companies to ensure wider coverage and more transparent claims settlement.

If the insured takes Buying their Health Insurance plan as seriously as buying other assets, this scenario will not arise. This is where distributors like Eindiainsurance also come into the picture. The insured can visit the website and spend quality time understanding the coverages and premiums before making a decision to ensure they get the optimum coverage at competitive premiums.

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