3 things about health insurance you ought to be careful about

The Economic Times 16/02/2023

"One has to be aware of the list of blacklisted hospitals. Second is the waiting period for specific illnesses. Third is the minimum time of hospitalization which is required for claiming a particular illness in your policy," says Ankit Agrawal, Founder & CEO, Insurance Dekho.

Let us talk about the common features of Health Insurance
Some of the basic features which everybody knows about as to why in India people started buying health insurances is because they wanted tax benefits. People are also aware that there are certain maternity benefits in a policy, people are also aware of the lifetime renewability of a policy, they are also aware of how and when a claim can be settled by a health insurance policy. These are some of the basic features which almost everybody would be aware of. They would also be aware of the coverage .

So whenever somebody asks for a hospital health insurance, they would want to understand what is covered, what is not covered but they would cover it at a very broad level and that is the sum insured which I am getting, the NCB protection which I will get say after one year of not claiming, how will it get renewed and till what time will it get renewed. These are the three or four common factors which everybody is aware of.

What are the things people do not know about and which are a part of your policy documents, your insurance policy documents, which people usually land up missing?

The most important feature which people miss out when buying a health insurance policy is a list of blacklisted hospitals. Because when you buy health insurance, you would want to buy a health insurance which covers the maximum number of hospitals. You may be buying health insurance with the assumption that the hospital which is located nearest to your house is covered, but the hospital may actually be a blacklisted hospital.

So, I would strongly urge all viewers of this show to look at the blacklisted hospital list first because it helps you understand which hospital you can go to in case of emergency and which hospital you cannot go to.
Some of the smaller hospitals or some people would try to do unlawful activities. They would fake claims and all insurance companies have their own investigation desk. So, in case the claim frequency from a particular hospital is very high, the insurance company would ask their investigation desk to investigate the hospital and on the basis of the investigation, they may decide not to continue the impanelment of the hospital. Once that is done, the insurance companies also share data with each other. This is the reason why hospitals can be blacklisted.

What is the second feature that is less known or not known at all?

One of the most important features which people overlook is the waiting period for specific illness. You cannot claim a policy immediately after taking the policy for an illness which you already had. There are certain illnesses for which there is a specific waiting period. Not all policies, for example, would also have a maternity cover on day one. They would typically have a 12-month or a 24-month waiting period for maternity coverage also.

The third and one of the most important factors which people overlook when buying a health insurance policy is the minimum time which is required for taking a claim. You cannot make a claim for OPD cover until and unless you have actually bought an OPD as a feature in the policy which you are buying. These are the three most important factors which people should look at.

So, one is the list of blacklisted hospitals. Second is the waiting period for specific illnesses. Third is the minimum time of hospitalization which is required for claiming a particular illness in your policy.

Last point, it differs for different types of health insurance companies. It differs from company to company or policy to policy?

It actually differs. Yes, it differs from policy to policy. It differs from company to company.

Talking about cashless claim, a lot of people go wrong over there also. How can one ensure and check before going in for a health insurance policy where they want a cashless feature and actually get what they are paying for?

There are two things; one, when you are getting yourself admitted into a hospital, typically all hospitals offer packages. As a part of your hospitalization, they will ask you whether you have health insurance or not. When you tell them the health insurance, they will tell you X percentage of the amount is going to be covered, Y percentage of the amount is not going to be covered.

So it is a fairly simple and straightforward process. I would urge all our viewers, in case they want to do any kind of planned surgeries, should understand from the hospital before getting admitted on what is the inclusion in their coverage, what is the exclusion in their coverage. This just saves a lot of hassles when you are getting discharged.

The worry for people is when their relatives are getting them admitted and they are not aware of what is going to be included, what is not going to be included. So broadly four checks on a health insurance everybody should do, and which people should also tell all their relatives.

One is the room rent coverage in their health policy which they have taken. Second, is whatever is the pre-existing diseases which they have declared while taking the policy.

Third, they should also talk about if they have taken any add-on like Hospi Cash. Hospi Cash is a very good add-on which I would urge all our viewers to take. Hospi Cash allows a person's relative to get some reimbursement. It varies from Rs 500 to Rs 2000 per day of hospitalization. This creates a smaller dent on your pocket. Last but not the least, the kind of restoration benefits which people have on the policy, because in case you are getting admitted for a planned surgery, but it is a very minor surgery which you can pay from your own pocket, that helps you save some kind of restoration, which we refer to as no claim bonus.

The feature of Hospi Cash, is it an add-on to your premium?

Yes, it is offered. In some policies it is offered as an add-on, and in some policies it is given as a part of the a-la-carte package.

Let us move on to the exclusions and inclusions that you just mentioned. I want to talk about the kind of illnesses which are included and the illnesses which have a waiting period. Although this is a standard list which all the health insurance companies should follow, a lot of time, people miss out on dealing with.

I will start with one of the most common diseases. It is thyroid. For anybody who is suffering from thyroid, there is a waiting period, or you have to take an exclusion when you are taking a policy that, any diseases related to thyroid will not be covered.
Second is pancreatitis and stones in the binary and urinary system. In case you have any kind of stone-related pain, or stone-related condition, that will not be covered, or they will have a waiting period. Cataract and glaucoma-related, eye-related diseases typically have a waiting period.

Also, it is not a disease, but we have spoken about pregnancy. Any pregnancy-related claims will have a waiting period in a policy. Anything related to your heart, if you already have a pre-existing condition, typically has a waiting period ranging from 12 months to three years. Also, any kidney-related issues which you have.

In essence, just to simplify, any existing medical condition will have a waiting period, or there will have to be any diseases arising or any claims arising due to that will have to be excluded. So the way health insurance companies work is, we are going to underwrite any future-related risk, but if there is a known risk to your body, we will not underwrite that risk or ask for a waiting period for that risk

Anything specific for senior citizens that people miss out on?

Our health insurance, the SAHI companies and the GI companies, have taken a lot of steps in this direction, and they have come out with specific products which cover senior citizens.

Star Health Insurance, Niva Bupa Health Insurance, Manipal Cigna, all of them have come out with great products which cover senior citizens. Earlier, there were a lot of concerns around this. For example, if somebody had cirrhosis or somebody had issues related to lungs, it was very, very difficult for a senior citizen, or somebody even suffering from diabetes, which has now become a lifestyle disease, to get insurance. But now products have been specifically created by health insurance companies which cover these.