Considering purchasing health insurance? Here are five things to look for in a policy document before you sign it.

Considering purchasing health insurance? Here are five things to look for in a policy document before you sign it.

Health insurance: Did you know that many insurance policies provide you with a free health check-up once a year? Continue reading to find out more about this and other topics.

Insurance policy documentation are difficult to read. However, if you don’t want to be caught off guard later, it’s critical to read a policy statement before signing up. Look for information on which expenses are and are not covered, the terms and conditions that limit how you can use specific benefits, and whether your overall cover (the sum insured) can be boosted by features such as restoration benefit, and so on.

In this article, we will look at five things to look for in a health insurance policy document. This list is not exhaustive, but it does show a few key differences between policies.

Waiting time

A normal 30-day waiting period, a pre-existing diseases / illnesses (PED) waiting period, and a customized disease/procedure waiting period are all available in a health insurance policy. That is, the insurance policy offers coverage only once the appropriate waiting periods have passed.

Expenses associated to the treatment of any disease within 30 days of the issue of your initial policy are not covered under the regular waiting period. This is a requirement in all policies. Accident-related claims are the lone exception.

Under the PED waiting time condition, coverage for any pre-existing disease begins only after a two to four-year waiting period from the date of the first policy’s issue. A PED is defined as any ailment or condition for which medical advice or treatment was suggested or received from a physician up to 48 months previous to the policy’s issuance.

Let’s have a look at an example. Assume you were diagnosed with diabetes in March 2018 and applied for and were approved for health insurance in January 2021. Then your diabetes, which was diagnosed during the last 48 months, will qualify as a PED. If the policy has a PED waiting time of, say, three years, you will not be covered for diabetes until the three-year waiting period expires in January 2024.

varying policies may have varying PED waiting periods. For example, Manipal Cigna Health Insurance Company’s ProHealth Prime Advantage plan only covers PEDs after 24 months of continuous coverage and a sum insured of Rs 7.5 lakh or above. The insurer has a 36-month waiting period for policies with a sum insured of up to Rs 5 lakh. After a 48-month waiting period, Bajaj Allianz General Insurance Company’s Extra Care plan covers PEDs. However, the company’s Extra Care Plus plan has a 12-month PED waiting period.

Finally, insurance policies have a waiting time for a certain group of diseases/procedures (related to specific gynaecological, orthopaedic, gastrointestinal disorders, and so on) as indicated in the policy document. These typically have a two-year waiting period, though this may be shorter in some situations.

Room rental cap

If you are hospitalized, your insurer may not always cover the full cost of your stay due to room rent. That example, even if your hospitalization expenditure is well within your insurance limit, your insurer may only reimburse your hotel rent to a certain amount. Alternatively, some insurers may define the type of accommodation that is covered by your insurance. In both circumstances, if you exceed the room rent cap or choose a room type that is superior than what you are entitled to, you will be charged the difference. These particulars will be mentioned in your policy paper.

If your sum insured under the Manipal Cigna ProHealth Prime Active plan is Rs 3 lakh, your room rent is capped at 1% of this amount. A single, private air-conditioned room is available to those with an amount insured of Rs 5 lakh or more. However, if you are admitted to the ICU, your room rent is covered as long as it is within the limits of your insurance. In all instances, Niva Bupa’s Health Premia (platinum plan) covers your room rent to the extent of the sum covered.

Under products such as Optima Suraksha, Optima Secure, and Optima Super Secure, HDFC Ergo General Insurance Company covers room rent based on actuals (actual expense incurred).

Periods preceding and following hospitalization

A health insurance coverage will cover not only your hospitalization costs (consultations, investigations, and medications), but also any connected charges incurred up to a few days before and after the hospitalization. This is true not just for in-patient therapy (real hospitalization), but also for domiciliary treatment (which ordinarily requires hospitalization but is performed at home due to factors such as the patient’s condition, etc.). This can vary depending on the insurance policy.

In the case of both in-patient and domiciliary treatment, the HDFC ERGO Optima Restore plan, for example, covers expenses up to 60 days before the date of hospitalization and up to 180 days after release. In the case of in-patient treatment, the Manipal Cigna ProHealth Prime Protect plan covers expenses up to 60 days before the date of hospitalization and up to 180 days after release. Coverage for domiciliary treatment is limited to 30 days before the date of hospitalization and 30 days after discharge.

Sum insured restoration / reloading

Check to see if your health insurance coverage has a restoration / re-loading benefit, which not all policies offer. This is a valuable tool that allows you to restore your insurance coverage to the initial sum insured once it has been exhausted. In a year where you have had to file several claims, it can give you and your family with appropriate health coverage. However, this benefit may be subject to a number of limits and conditions.

Many plans, for example, may prohibit you from using the restored sum insured for claims involving the same disease or damage to the same individual for which a claim has already been paid in the same year. That’s how this benefit works in plans like Manipal Cigna ProHealth Select and Royal Sundaram Family Plus. For example, if Mr A has previously made a claim for condition XYZ, he cannot use the restored sum insured for another XYZ claim in the same year. He can, however, file another claim for another ailment. In the case of a family floater policy, Mr A’s spouse can file a claim for the XYZ illness. However, other policies, like as HDFC ERGO Optima Secure, do not have such limitations on the recovered sum insured.

The restoration benefit is only available under all policies after the second claim. So, if your first claim for the year is for Rs 6 lakh and your base SI is Rs 5 lakh, you must bear Rs 1 lakh. Furthermore, any unused restored SI cannot be carried through to the following year.

Health examinations

Many insurance policies provide you with a complimentary health check-up once a year. However, there may be deviations. Read the policy document to learn more about what is available. For example, under the Niva Bupa Health Premia Policy (silver and gold plans), you become eligible for annual tests of Rs 1,250 to Rs 7,500 per insured person, depending on the sum insured.

A health check-up is only offered once every third policy year under the ManipalCigna ProHealth Protect and Accumulate plans, but it is available every policy year except the first year under the ProHealth Plus, Preferred, and Premier plans. Furthermore, depending on the plan and the amount insured, you may be qualified for a certain list of tests.