10 Unknown Facts of Health Insurance

Health Insurance in India has become the “need of the hour”. Life is moving at rapid pace and has certainly become unpredictable. A situation of emergency can arise at anytime and anywhere regardless of the person’s age, gender and the kind of lifestyle he /she lives. By now we are all aware of the importance of health insurance policy in today’s world.

However with inflation and rise in cost of living of a common man, there are chances that there are some hidden or undisclosed facts on your health insurance policy. Your health insurance provider may not disclose these facts while buying a health policy.  It could be related to your hospital expenses or policy terms and conditions etc.

To secure your beloved family members financially against any health issues, it is important to have a first-hand knowledge of these facts, before buying a health insurance policy.

Let’s have a look at some of the unknown facts of health insurance.

  • Room Rent clause

Not many know that the room rent is 1% of your sum assured. And at the time of hospitalization, if you choose a room over and above your room rent, all expenses related to hospitalization will automatically increase.

Example: In case you buy a health insurance policy offering a sum insured of Rs.5 lakh, your room rent will be Rs.5,000. However, due to unavoidable circumstances if you choose a room that charges a rent of Rs.8,000, all other expenses will be charged as per your room rent charges. (Which in this case is Rs. 8,000)

  • Co-pay

  • To define co-pay in a correct manner, it is portion of claimable bill that you as a policy holder agree to pay from your own pocket. It is mostly 10- 20 %.

Example: If the claimable amount is Rs. 1 lakh, you are entitled to pay 10% co–pay. This means the amount payable by you will be Rs. 10,000 and the remaining amount will be paid by the insurance company.

  • It is ideally advisable to choose a policy with a no co-pay.

  • No-sub limits

  • The sub limits are those monetary caps which is placed by your insurance company. These are mostly applicable on surgeries including cataract, cerebrovascular accident, cardiovascular disease and kidney stone etc.
  • Example: In a classic case, say the hospital bill is Rs. 1 lakh and the patient hospitalized has kidney stone. As there is a sublimit in the policy, you will have to bear Rs.40,000 from your pocket and the remaining amount of Rs.60,000 will be borne by the insurance company.
  • Thus it is advisable to select a policy with no sub limits

  • Zone wise Premium

  • Yes sometime, something like this exits! There are certain insurance companies that charge the health insurance premium city wise and state wise. In case like this, if you happen to get hospitalized in some other zone, other than from where your policy belongs, you are bound to pay the charges as per the hospital (under which zone) you get hospitalized.
  • For example: Mumbai, Navi Mumbai, Delhi falls in zone 1 for an insurance company and Hyderabad, Kolkata, Cochin etc falls in zone2. Due to some emergency you get hospitalized in zone 2, however your policy belongs to zone 1, then the claim charges will be considered as per zone 2.

  • Difference between restore and recharge

As a customer, there are some benefits you drive apart from getting your regular claim amount. Those benefits are the “Restore” and “Recharge” benefits.

  • Restore benefit: When the sum assured of your policy is exhausted, the insurance company will restore the sum assured for you. However, in this case, the claims should be unrelated which means claim has to be for different person or claim should be for a different disease.

Example: If you want to claim for a back operation, with restore you cannot claim a second claim for the same problem.

  • Recharge benefit: In case if you want to utilize the recharge benefit, the only condition is that the claim has to be unrelated.

  • It is always advisable to buy a recharge benefit.

  • Difference between top up and super top up

The industry introduced this gem of product to support your base plan. However there are important conditions to keep in mind whilst buying these policies.

  • Top up policy: It is compulsory to exhaust the deductible amount in every claim.
  • Super top up policy: In this type of a policy, you have to exhaust the deductible amount every year.
  • It is hence advisable to buy a super top policy.

  • Waiting period on exclusions

  • Any claim arising due to illnesses such as spinal disorders, arthritis etc.,  or surgical procedures shall not be considered for the first 2 years of the policy. Most of the insurance providers have the same kind of exclusions. There isa list of almost 20-24 exclusions.
  • Just to name a few: Arthritis (if non effectives), Osteoarthritis and Osteoporosis, Gout, Rheumatism and spinal disorders, Joint replacement surgery.
  • Important point to remember is that, do ask the insurance company about the list of the exclusions and read the health insurance policy wordings carefully.

  • Network hospitals
  • All insurance companies have their list of network hospitals. Since these lists are updated quite frequently, it is necessary to check them. This list is available online on the insurer’s website.
  • Also, in case of an emergency, if the network hospital is not nearby or there are no beds available in the hospital, one can go to any other hospital. The claim will be then filled under reimbursement, wherein you will have to first pay from your pocket and later it will be reimbursed by the insurance company.

  • Disclosure of pre – existing diseases

  • There have been cases, where the insurance company has denied claim or has cancelled a health insurance plans policy. One of the most prominent reasons being non-disclosure of pre-existing disease/ surgeries if any / any kind of symptom etc.
  • Point to remember here is that, it is therefore necessary to disclose all facts to the insurer before buying a health insurance policy.

  • Change in premium

There is some misconception about the health insurance policy premium, that they remain constant, however most of the insurance companies change or revise the premiums every 5 years.

Let’s throw some light on the reasons to buy health insurance policy and discuss how to get the best plans.

Reasons to buy health insurance policy

  1. Almost a life supporter in case of a medical financial crisis
  2. With a health insurance policy you have more power to get better medical facilities
  3. You get a tax benefit under section 80D of the Income Tax Act
  4. You get a sense of security

How to get the best plans?

Getting best health insurance plans online is not at all tricky. Just keep the following guidelines in mind.

  1. Comparison of health insurance on basis of type of insurance. Please check if you are looking for critical illness or the normal insurance policy.
  2. Choosing a plan on basis of coverage
  3. Comparing health insurance of different insurance companies
  4. Looking for added benefits and offers




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