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Health Insurance FAQs
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Q- Why do I need health insurance if I am young and healthy?
A- We need Health Insurance to take care of future medical expenditures that may arise at any point of time in our lives. Medical insurance takes care of the financial aspect of emergency medical situations or even planned treatments that cost a lot. Moreover as we age, we may develop certain medical conditions. These are considered Pre-existing illnesses at the time of taking a new health insurance Policy and are covered after a long Waiting Period by insurance providers. In certain conditions for pre-existing diseases, health insurance may even be denied. It is better to buy a Mediclaim before any such situation arises.

Q- What does health insurance cover?
A- It covers almost all hospitalisation expenses for a minimum period of 24 hours. Certain day care procedures are also covered. The cover includes accidents, surgeries and other medical procedures, hospitalisation costs of room and other facilities, and medication. Still it is always better to go through the whole policy document to know where you stand when you make the claim. Look for the specific wordings in the policy document regarding Exclusions , Cashless Hospitalisation , Reimbursement, Network Hospitals , Room Ren t, No Claim Bonus , Loadings and, Upper Age Limits etc

Q- Do I need separate health insurance if my employer is providing it?
A- Experts advise on taking separate Health Insurance even if your employer is providing it (technically called the group health insurance or group mediclaim) as jobs have uncertainty attached to them:
• Employer provided health cover lapses the moment you retire or change the job.
• When you change the job you might not be covered during the transition period.
• Group health insurance does not offer any continuity benefits to the insured.
• Your new employer may not provide you with health insurance.
• You may not be able to buy a new insurance Policy at the retirement age (upper Age Limit ) or may have the premiums are too high to be effective.
• Services and conditions covered in a group insurance plan by an employer may differ from your own requirement.


Q- Why should I maintain continuity in health insurance?
A- Maintaining continuity is important to avail the long term health insurance benefits. When you take a personal or standalone health insurance, and renew it regularly, you start getting continuity benefits that prove to be invaluable over the time:
• 30 days waiting period is waived off on renewal.
• Disease exclusions for the 1st year and 2nd year are waived off on 1st and 2nd renewals respectively.
• You start getting no claim benefits.
• Pre-existing diseases are covered after 3-4 continued policy years.
• Maternity cover may be there only after 2-4 continued policy years if available.
• Some insurance companies offer free health checkups after four continues policy years without claim.
• Group insurance may lapse at a time you need health insurance the most (after retirement or during uncertain employment times).


Q- How much health insurance do I need?
A- As much Health Insurance as you can afford is what you need. Since it is difficult to anticipate an emergency that you might get into, a look into family medical history your age and past medical records, your lifestyle hazards, and you can get a rough estimate insurance required. How much Premium you can afford to pay and sudden expenditure you can bear during an emergency also are the questions that finally decide the insurance cover you finally opt for.

Q- What type of health insurance should I take?
A- There are largely two types of health insurance covers available in India.

• Individual Health Insurance
• Family Health Insurance

Along with these there are options like personal accidental benefit, critical illnesses plan, senior citizens policy and hospital cash that can be taken as riders or individual policies. Choice can be based on individual age, family status, and health condition as to what type of policy or rider may be most suitable.


Q- What is individual health insurance?
A- It is the most traditional health plan wherein an individual is covered for medical and hospital expenses up to the sum insured. The Insured individual is entitled to the entire sum insured of the policy. Such plans are most suited for high Risk individuals or the families in higher age slabs. The Proposer (buyer) can purchase an individual health Policy for himself, his dependant parents, spouse, and kids.

Individual health plans have higher premiums if bought for each member as the cover offered is also higher as a whole.


Q- What is family floater health insurance?
A- This type of a policy covers more than one member of the immediate family under a single plan and the sum insured is available to entire family covered in the plan. One can buy a family floater policy for:

• Self and spouse
• Self, spouse and kids
• Spouse and kids
• Self and kids

The premium paid comes out to be less than the one paid for individual cover for all in family. This is considered suitable for young nuclear families with lower health risks. When required each insured individual is entitled to part or total ensured amount for the family. A limitation may arise in case of more than one claim in a year as the amount remaining after the first claim is reduced.


Q- What are exclusions?
A- Exclusions list diseases consultations, tests, and hospitalisations that are not covered in a mediclaim. For example, some policies cover OPD costs, ambulance costs and tests, others don’t. The e exclusions list of different insurance companies may vary. Still there are certain permanent exclusions that need to be looked into:
• Expenses arising from HIV or AIDS and related diseases.
• Abuse of intoxicant or hallucinogenic substances like drugs and alcohol.
• Hospitalization due to war or an act of war or due to a nuclear, chemical or biological weapon and radiation of any kind.
• Items of personal comfort and convenience.
• Experimental, investigative and unproven treatment devices and pharmacological regimens.
• Expenses which are mainly cosmetic in nature.


Q- What is cashless facility?
A- Cashless facility allows the insured to be treated at select hospitals without paying in cash at the network hospitals. To avail this facility, the insurer or the assigned TPA must be informed in advance in case of planned treatment and within a stipulated time in case of emergencies.

Q- Why do I need reimbursement if my insurers provide facility of cashless treatment?
A- In some instances, it may be required to take the Insured to a hospital that is not a network hospital or the TPA was not contacted on time. In such cases the insured can Claim the medical expenditure within a stipulated time of the commencement and completion of the treatment. Reimbursement offers an amount of time flexibility while getting the medical aid.

Q- What are network hospitals and why should I look for them?
A- Every health insurance company has tie ups with various hospitals through their TPA where they provide cashless facility to their customers. It always comes handy to know the network hospitals of your insurer in your vicinity or look for a company that has one in your surroundings. Also take into account the quality of these hospitals.

Q- What is room-rent capping?
A- Hospital charges rent on the room that one takes at the time of hospitalisation. Some insurance companies put a cap or a limit on how much a person is eligible for the room rent per day at the hospital. One needs to compare it with the rates of the hospitals one visits. These norms vary for each Health Insurance company.

Q- What happens if I do not make a claim in the whole year?/ what is no claim bonus?
A- When the insured sticks to one company, he is assured certain benefits over the years in case of no claim. Some offer more sum assured and others offer some reduction in future premiums. Some insurers may stick to the same premiums but may offer other kind of benefit or services like free health checkups for continuity.

Q- What is loading?
A- In a Health Insurance policy, Loading is the amount that is added to the Premium after a Claim is made. The percentage increase depends on the age of the Insured amount and type of claim. Certain types of loadings can be there even at the time of buying a Policy depending upon the age, Pre-existing conditions, or current health status.

Q- What is co-payment?
A- Co-payment means that the insured has to make the partial payment of the treatment. This comes into play usually when we take treatment in non-network hospitals or in the higher age slabs. Every company offering health insurance has a different rule pertaining to loading and co-pay and it is always better to go through the norms before buying.

Q- What are riders and add-ons?
A- To cater to specific requirements of individuals and families most Health Insurance companies provide customisation of a medical Policy by giving Riders or add-on benefits like critical care policy or personal accidental benefit to the main policy. Opting for these adds to the Premium cost but at the same time adds to the sum Assured in critical situations.

Q- What is a critical care policy?
A- Critical care policy provides an added cover over a regular health plan in case of critical illnesses like heart attacks, heart surgery, cancer (baring certain kind), organ transplant, stroke, paralysis, burns, and other prelisted illnesses. List of critical illnesses covered may vary for each insurance company.

Critical illness cover can also be taken as a rider along with health insurance and life insurance. In this case the person insured becomes eligible for increased cover if diagnosed with a critical illness i.e. sum assured for critical illness + sum assured for health insurance.

The disbursement rules may vary. In many cases the insured amount is disbursed as a lump sum the moment a critical illness is diagnosed though some companies may disburse it in parts at regular intervals or as the bills are produced up to the sum assured.


Q- What is personal accident Policy?
A- Personal Accident Policy is suitable for people facing high accident risk. It can be taken for self as well as for family. Amount of Claim depends on the type of disablement (permanent, temporary, partial, and total) up to the limit as mentioned in the policy wording.

Q- What is a senior citizen health policy?
A- There was a time when people above a certain age usually the age of 60 years or 70 years, were not entitled for health insurance. Now there are a few insurance companies offering senior citizen health plans or have increased the upper age limit. Senior citizen health insurance plans may have a higher premium and may also have an upper age limit for entry into a policy or the maximum age up to which they will be provided the cover.

It is very important to go through the terms of policy regarding exclusions, upper age limit, co-payment terms, and coverage for facilities like room rent and ambulance cover while taking a senior citizen health plan.


Q- What is hospital cash?
A- Hospital cash is a fixed allowance that one is entitled to in case of hospitalisation. The daily cash allowance can be used to cover miscellaneous expenditures that may otherwise not be covered in a health plan. One may take hospital cash along with a regular health policy.

Q- Does health insurance cover me for maternity or pregnancy related expenses?
A- Most insurance companies do not cover maternity or pregnancy related medical expenditures though some companies offer this cover for people who have been already insured with them for a fixed minimum duration that may range from 2- 4 continued policy years depending upon the insurance company.

Q- Does health insurance cover consultation and diagnostic charges?
A- Not all the consultancy charges and diagnostic tests are covered in a health policy. Most insurance companies cover it only if:
• Consultation and diagnostic charges are part of an ongoing treatment for which you have been admitted to hospital.
• They result in diagnosis of a situation for which you have to be admitted to hospital.
If the tests conducted are not related to the hospitalisation for a specific treatment then they might not covered.


Q- Till what age will I be covered?/ what is the upper age for a health policy?
A- Every health policy has a maximum age for entering into a policy and the maximum age up to which the person might get the health cover. These are called upper age limit and renew up to limit respectively.

Most health insurance companies limit the upper entry age into health insurance between 55 to 60 years and provide health cover till age of 65 to 80 years as per the norms of different companies. Some insurers have a different premium plans for different age groups, others offer health insurance for life and provide insurance to senior citizens with specific conditions attached as per the company policy.


Q- What is a TPA or Third Party Administrator?
A- TPA or the third party administrator is the link between the insuring company and the Insured person. Any facility provided by your insurance company is through the TPA. These companies are licensed by IRDA and are authorised to represent an insurance company. One TPA may cater to more than one insurance company or the insurance company may have their own in house TPA services. They coordinate between the hospital and the customer for cashless treatment and handle claims and also offer guidance to the insured whenever needed. The toll free numbers and contacts provided to you after insurance are that of the TPA.

Q- Can I and my family be covered under the same policy if we are staying in different cities in India?
A- Yes, you and your family can be covered under the same family policy even if you are staying in different cities in India. You just need to make sure that the network hospitals are available at both the places for ease of claiming the cashless facility.

Q- Does health insurance cover alternate medicine like naturopathy or ayurveda?
A- No, no alternate medicine like ayurveda, naturopathy, or homoeopathy is covered in health insurance. It covers only the allopathic treatments.

Q- Can I buy more than one health policy?
A- Yes, you can buy up to two health policies provided you declare the same to both the insuring companies. You cannot claim the whole amount from both the companies. The claim is divided amongst the two companies in the ratio of sum insured from both the companies.

Q- Do I need to undergo a medical examination before buying health insurance?
A- For buying a new health policy, medical examination may be required for people over 45-50 years of age depending upon the company policy.

Q- What is a waiting period when I buy a policy?
A- There is a minimum 30 days waiting period from the date of the policy coming into effect when you are not covered for anything except accidents. For some companies this waiting period may extend up to 60 to 90 days. Further there are waiting periods for specific medical conditions and pre-existing diseases is much longer (ranging between 1-6 years) during which you may not be covered for that particular illness e.g. for cataract surgery most companies have a waiting period for one year of policy duration.

Q- Can I seek treatment at home and be reimbursed for it under health insurance?
A- Yes, it is possible to seek treatment at home and be reimbursed for it called domiciliary treatment, provided basic conditions for the same are fulfilled:
• The person is not in a condition to be shifted to the hospital.
• The person cannot be accommodated in the hospital for lack of beds or other infrastructure.
It is always better to seek advice from the company representative regarding such issues as they are always treated as exceptions.


Q- What are day-care procedures? Are they covered by my health policy?
A- There are certain medical treatments that do not require you to get admitted to the hospital for more than a few hours like dialysis or chemotherapy etc. Such treatments are called day-care procedures. Many of these are covered by the health insurance. The list of day care procedures covered may vary for different insurance companies.

Q- What is the minimum and maximum policy duration?
A- Any Health Insurance is for a maximum duration of one year and needs to be renewed after that though some companies may offer it for 24 months.

Q- What is coverage amount?
A- Coverage amount is the maximum amount you are eligible for in case of a claim for a policy term (one year in most cases).

Q- How many claims can I make during a year?
A- You are Insured for a fixed amount in a year called the Coverage amount or sum insured. You can make as many claims till you reach the value of sum insured.

Q- What is a pre-existing disease?
A- Pre-existing illnesses are the medical condition, ailment, or injury prior to inception of your first health insurance policy. These may be conditions for which you had symptoms, were diagnosed with, or received treatment for, before buying health insurance. If insurance company once accepts your proposal then they are covered after certain time period, mostly four year of continued policy renewal.

Q- How does the insurance company decide if a disease is pre-existing?
A- When you fill the Proposal form for your Health Insurance you need do declare any medical condition you may have and you also need to declare family medical history. Based on these conditions the insurance company decides if you have a Pre-existing disease. It is done in good faith as per the declaration made by you.

It is advisable to fill the form true to your knowledge as a Claim may be denied if the situation is found to be otherwise at a later stage.


Q- Am I entitled to buy health insurance if I have a pre-existing problem?
A- It is insurance company’s discretion to except or reject your proposal if you have a pre-existing problem. If the case is accepted then there might be a loading on premium or a waiting period for that condition to be covered in a health policy as per the company norms.

Q- I am a foreign national. Am I entitled to buy a policy in India?
A- Anyone living in India or visiting India for employment, education, or even tourism is entitled to buy Health Insurance here provided the person is not visiting here for medical tourism or for treatment. The Coverage area is limited to India. Waiting Period for the insurance to be effective remains the same (30 days) so it is not advisable for those on a short visit.

Q- What happens if I want to cancel my health policy?
A- If you wish to cancel your policy before the maximum duration of the policy, your insurance will cease to exist and a part of your premium will be refunded to you. Terms of policy cancelation are mentioned in the policy document and may vary for every company.

Q- Does a company have a right to deny health insurance to a person?
A- Yes, a company can deny Health Insurance to a person based on certain conditions like Pre-existing diseases, general health conditions, or age.

Q- What happens to the coverage after I file the claim?
A- After you file a claim the total cover available for the rest of the year is reduced by that much amount.

Q- Who gets the claim if the policy owner dies during a treatment?
A- In case of cashless treatment the bills will be settled directly with the hospital. In case of Reimbursement the amount is paid to the nominee or the legal successor on presentation proper documents like bills, death certificate succession certificate.

Q- What documents do I need at the time of buying a health policy?
A- Other than the proposal form, premium cheque, and individual photographs of the insured persons, you may need a photo ID proof, age proof, and medical examination papers as per the norms of the insurance company.

Q- Do I get tax benefit if I buy health insurance?
A- Yes, you can avail annual deduction of Rs. 15,000 from taxable income (20,000 for senior citizens) on payment of Health Insurance of self and Dependants under section 80D. (Tax benefits under section 80D are different from the Rs1,00,000 exemption under Section 80 C)

Q- What determines the premium of my health insurance?
A- Age of the person to be insured and the amount of cover required are the two main factors that decide the premium of health insurance. There might be other factors like pre-existing diseases facilities covered etc.

Q- Should single men and women choose an individual policy with good maternity benefits?
A- Individual policies usually do not carry maternity benefits. But, there are some policies that cover you for maternity benefits after 6 years. These benefits may only be availed by women as the cover is valid for the Insured individual. On the other hand, when men get married, they may include their partner in their existing individual Policy by converting it to a family floater policy. They may then avail maternity benefits after the waiting period, which is usually 2-4 years after conversion to family floater, depending upon their chosen policy.

Q- Who should choose maternity benefit in their policy?
A- Maternity benefits may be an important feature in your health insurance policy if you are availing it as a couple (family floater) and are planning to conceive within 2-4 years. Remember, you must choose the policy, in which the waiting period (usually 2-4 years) co-incides with your family planning.

Q- Will my claim be rejected if I use tobacco?
A- It entirely depends on the medical Underwriting and claims underwriting decision. They can issue your Policy but charge higher Premium due to Risk oriented habit. Also, the Insurer may issue the policy but according to the quantity you use, the Coverage of policy can be limited. If you declare that you use excessive quantity of tobacco then the insurer may even refuse you the policy. However, if you do not declare in the Proposal form that you consume alcohol, do not smoke or do not chew tobacco and after few months or year later you are diagnosed with such disease of liver which is mainly due to excessive consumption of alcohol(alcoholism) or cancer due to excessive use of tobacco, your Claim will be rejected due to non disclosure fact. Therefore, your claim may be rejected if you use tobacco, only if you do not disclose the fact. Please remember to disclose all facts accurately to avoid rejection of your claims.

Q- What is Convalescence Benefit?
A- After a long period of hospitalization, a policyholder may not be able to get back to work immediately. This means there may be a loss of income. At this point of time, he/she may need extra funds to take care of the household expenses, medicines, etc. Convalescence benefit is an additional benefit offered with health insurance to take care of such expenses.

Q- During the course of treatment can I change my hospital?
A- Yes, you are allowed to change the hospital on the grounds of better treatment and services, but you need to first inform your TPA who will evaluate your case on the basis of Policy terms and conditions.

Q- What is capping in Health insurance?
A- Capping is the maximum amount one can avail under different heads covered in the health insurance plan, like room rent and ICU charges. If expenses come out to be more than the specified limit, then these are to be borne by a policyholder.

Q- What is the concept of zone wise co-payment?
A- Insurance companies have divided cities and towns into categories with those residing in small cities have to pay low premiums. Customers are required to select the zone where they are likely to make a Claim at the time of hospitalization. If they claim in a higher zone they would attract 10-20% co-pay. For instance, if you live in Surat (Zone III) and you make claim in Delhi (Zone I) then you have to foot 20%admissible Hospitalization expenses as co-payment.

Q- How Can I trust Cigna TTK since it is a new entrant in the insurance market?
A- Insurance is the contract of trust, therefore, your concerns about Cigna TTK is obvious. We would like to apprise you about the brand names which are associated with this insurance company. Cigna TTK is a joint venture between the US based global health services Cigna Corporation and TTK Group, a household name with brands like Prestige pressure cookers and also a TPA. Cigna is one of the largest providers of health management services and insurance. Operating in over 30 nations, Cigna has a wide base of more than 80 million customers. So it is completely safe to buy an insurance product from Cigna TTK.

Q- Can I take multiple health insurance policies? How will I make a claim in that scenario?
A- Yes, you can take multiple health policies from the same company or from different insurance companies but it is important to inform about the existing policies to the other Insurer while buying a Policy or at the time of making a claim. If you fail to disclose it, then it means you are violating one of the important terms and conditions of the Health Insurance company and in case of investigation this could be counted as misrepresentation.

Let’s understand the Claim procedure by taking into account different scenarios.

Scenario 1: When total claim amount is less than the sum Assured under a single policy In case of Indemnity policies like Mediclaim or hospital Reimbursement type insurance, if the Insured opts for multiple policies in the same tenure and the claim amount is less than the sum assured, then insured has all rights to choose from which insurer he wants to make a claim. For instance, Mr. Sharma has Rs 4 lakh insurance policy from Insurer X and Rs 2 lakh policy from Insurer Y. The claim amount is Rs 2 lakh. In this case, the insured can choose any insurance company who will be bound to settle the claim as per terms and conditions.

Scenario 2: When claim amount is more than the Sum Assured under a single policy In this case, insured has all rights to choose the insurer who will settle claims. However, if at the time of a claim settlement, insured doesn’t disclose about other policies, then the insurer’s liability is restricted up to the sum assured and the Policyholder will have to bear remaining expenses.

Scenario 3: Claim under defined benefit policies If the insured has got defined benefits like Critical Illness where claim doesn’t have any relation with the treatment cost and the payable amount is fixed, then insured will be entitled to get benefits from all policies.

Here the real mantra is to make a claim under the old policies wherein insurance has past the Waiting Period for a lot of ailments.


Q- What are the tax benefits available on Health Insurance?
A- As per new tax slab, health insurance premiums up to Rs 25,000 will be subject to tax deductions. For senior citizens, the limit is increased from Rs 20,000 to Rs 30,000. Tax deductions for expenditure towards ailments of specific nature have increased from Rs 20,000 to Rs 80,000 in this year’s budget. Rs 25,000 deductions are allowed for differently-able people.

 
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