Points to Remember: When You Opt for a Mediclaim Policy

A health insurance policy or a mediclaim often remains quite misunderstood. Here are a few points to ponder before completing the formalities of filling out the form for a health insurance policy.

ADEQUATE SUM INSURED: Essentially, the sum insured is the maximum value for a year that the insurance company can pay in case an individual is hospitalised. Any amount above and beyond the sum insured will be required to be shelled out from the pocket of an individual.

The sum assured may be the same but premiums tend to vary across different insurance companies. It is suggested to compare features instead of zeroing in on the cheapest plan. Always pick the right policy for yourself basis cost versus value proposition. It is crucial to not look at the premium paid alone for the policy but the overall value that is being offered must be considered.

WAITING PERIOD AND PRE-EXISTING DISEASE (PED) DISCLOSURES: In the health insurance industry parlance, a waiting period is the time span after the purchase of the policy during which one cannot claim any benefit from the insurer. The terms and condition of the waiting period vary from company to company and depends on various other factors. 

Further, if a customer is already suffering from a pre-existing disease (PED) then the waiting periods should be compared across products. According to the Insurance Regulatory and Development Authority (IRDA), a pre-existing disease is any condition, ailment, injury, or related condition for which one had signs or symptoms, was diagnosed, or received medical advice or treatment in the 48 months before the purchase of the policy.

SUB-LIMITS AND CAPPING: Capping or sub-limit is the maximum amount one can avail under specific heads covered in the health insurance plan. Some health insurance plans come with sub-limits or capping on the room rent, diagnostics and doctor’s fees. For instance, insurance companies have a cap on room rent which is usually 1% of the sum assured per day. This figure varies from company to company.  Ideally, one must choose a policy that offers minimal or no sub-limits or capping. 

POLICY WORDINGS: It’s important that the consumers read the prospectus carefully and understand policy wordings before purchasing any insurance policy. 

EXCLUSION CLAUSE: The health insurance policy also excludes certain conditions and ailment, which is mentioned in the brochure. For example, plastic or cosmetic surgery (unless these are a part of medically necessary treatment), self-destruction or self-inflicted injuries, attempted to suicide or suicide, use of intoxicating drugs and alcohol, war or any act of war, breach of any law with criminal intent.

CRITICAL ILLNESS COVER: In addition to a standard health insurance plan, one could also look forward to also invest in a critical illness plan to create a second financial buffer. A critical illness plan is akin to a health insurance plan that pays a lump sum amount, equal to the sum insured, to the insured on acquiring a serious ailment such as cancer or a stroke. A critical illness cover provides a lump sum benefit that can pay for the cost of care and treatment, recuperation expense, and even pay off any debt if taken. Regardless of your hospital expenses, the insurer pays the full sum insured. 

IN CASE OF DISPUTE: In case a policy-holder is not satisfied with the response from the insurance company, one may follow the below escalation matrix:

  • File a complaint with the insurer through the e-mail id or on the toll-free number provided on the insurer’s website
  • In case the responses provided by the insurer is non-satisfactory, a policy-holder can contact the chief grievance officer of the insurance company whose details are available on the policy and on the insurers’ website as well 
  • If a policy-holder still needs to escalate the matter, one may write to the grievance cell of the Insurance Regulatory and Development Authority of India (IRDAI) for a resolution

Further, a policyholder may also take up the case with the insurance ombudsman, created by the government of India for policyholders, to have their disputes settled in an impartial way.

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