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The Necessity Of Health Insurance – What You Can Expect

By Expert Author: Artham Vidya

A couple of years back my mother underwent a cataract operation. Cataract surgeries are very common and can be done anywhere, but we wanted to provide her with the best possible experience (my mother is terrified of hospitals).

She was admitted to a multi-speciality, which provided good care while we ensured that the lenses being used were of high quality. The entire package, including the one-day stay in hospital and other medications came to just about Rs 80,000.

Fortunately, since she had medical insurance, the entire amount was reimbursed.

My brother recently had to undergo spinal surgery for a disc displacement. The cost of the operation, the pre-operative and post-operative medications and the hospital stay all amounted to more than a lakh of rupees. Again, the entire amount was reimbursed by his insurance company.

A gentleman I know has been undergoing kidney dialysis every fortnight for the last ten years. He is a salaried individual with a government company. Anyone who is suffering from kidney failure knows the kind of expenses that they have to bear – not only for dialysis but also for the medicines that have to be taken regularly.

Again all his costs are being taken care of by his health insurance.

Medical costs are going up but few people pay much attention to getting a health cover. In India, life insurance is sold with a great deal of aggression and but the same kind of aggression is not displayed in the case of medical health cover. Though things have changed over the last few years, the awareness of health insurance still remains low.

While hospital and medicine costs in India are much less compared to the developed countries in the world, we have to realise that India’s per capita income is fairly low. The government has done its bit towards providing affordable healthcare through municipal hospitals and government-run clinics, but we know the kind of situation that prevails in some of these hospitals.
Sometimes we have no option other than to seek treatment from a privately run hospital and the costs of treatment here can be crippling, especially if one has to stay for a week or more.

When we are young, sickness and ill health are the last things on our minds – but we know that one can become ill or contract a disease at any age. There is also reluctance among most people to pay a premium every year for the insurance cover, especially when we know ourselves to be in good health.

It is only when we suddenly fall ill and require hospitalisation that we realise how much we have to pay for the treatment.

When you go to bed every night, don’t you make sure that the doors are all properly locked and barred? Don’t you keep all your valuables under lock and key or in a locker? Think of medical insurance as a kind of protection and safeguard for your health-related costs.

Let us take a look at what exactly you can get from a health cover. Of course, it will vary from insurer to insurer but mostly it will be along similar lines since it is all governed by the Insurance Regulatory Development Authority (IRDA).

One thing I would like to stress is that when you sign on for a health insurance package, take a look at the inclusions and exclusions. For many diseases, it takes about four years of uninterrupted, claim-free coverage before you become eligible to make claims.

Also, while filling up the form if you have undergone any surgeries, illnesses or have been hospitalised for any reason (however minor) be sure to disclose it. This is just so that you do not have any problems while making a claim later and your health insurer should not be able to state that you hid anything from it.

Anybody from 18 to 59 years can apply for a health cover and this can be renewed up to the age of 80 years. The minimum cover you get is Rs 50,000 and the maximum is Rs 5 lakh, though these days you can get top-ups over and above this, depending on your health and claims history.

You can either insure yourself on an individual basis or also take a family package. Your dependents such as your parents, spouse and children are generally covered within your policy.

Hospitalisation benefits covers room rentals, nursing expenses, consulting fees of doctor and surgeons and all costs related to operating procedures. What portion of the sum assured you get for each category depends on your insurer.

There are packages, which also reimburse ambulance charges provided you utilise a registered ambulance service and if you use it for emergency purposes.

Earlier, insurance companies would not honour claims for pre-existing conditions – that is diseases, which you already have at the time of taking the policy. But now that has been relaxed and if you have four consecutive claim-free years then you can get cover for that too. But there are still some grey areas over pre-existing conditions and you need to go over the policy with your insurer to be clear about what you can claim or cannot claim. As I said earlier, transparency is key.

In all cases what is important that is once you have taken a policy, renew it every year before the due date. Any breakage and it is treated as a fresh policy and you have to begin all over again.

You can also avail of cashless claims where you don’t have to spend a penny and the settlement takes place between the insurer and the hospital. For that, you have to be sure that the hospital where you or your family members are being treated is empanelled with your insurer for the cashless facility.

Make sure that you have all the necessary documents with you – that is, the hospital should give you documentary proof of every procedure that has been undertaken, including bills for all the medicines and equipment that has been used.

You should not feel regret that you were unable to get a loved one treated in the best hospital available because of lack of money.

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