Health Insurance Customers - Know Your Rights

Are you one of those Indian Citizens who thinks that fighting with Insurance Co's is a Lost Cause? Are you one of those people who think that Insurance Customers are forced to accept the decisions taken by Insurance Co's? If so, this article is for you. In this article we are going to cover the basic rights that you and I have as Health Insurance Customers.

Right No.1 - The Premium Amount has to be Justified

Yes, the Insurance Company fixes the Premium for all Insurance Policies sold by them. But, this does not mean that they can just quote any number they want.

First of all, they have to submit their Premium Amount calculation details with IRDA when they register the Policy. If you jumped the gun and said "How will I know whether I am being Over-charged?", don't worry my friend. I am just getting to the Good Part.

There is something called a "Premium Chart" which every Insurance Company has to put up on their website. This will contain details on how the Premium Amounts will vary based on the policy holders age, claims history etc. Practically, premiums go up during renewal of Health Insurance policies if, the policy holders age goes up or if claims were made in the previous year. By knowing these details you can check the website and confirm if the premium you are paying is appropriate for the policy you are purchasing.

Tip: If you are still not sure of whether you are being over-charged, compare similar products offering similar insurance benefits from other Insurance Company's. The difference in premium must not be more than a few hundred rupees. For ex: If LIC Offers me Health Insurance worth 10 lakhs for Rs. 15,000/- per year and if ICICI Prudential asks me Rs. 30,000/- for the same policy, then either of the following is true:
1. ICICI Prudential is probably offering me much higher benefits than the policy offered by LIC
OR
2. ICICI Prudential is over-charging me

Note: The above is just an example. I am right now working abroad and have practically 0 idea about the current prevailing Health Insurance policy premium rates in India.

Right No. 2 - Policy Renewal cannot be Refused without a Valid Reason

There are numerous cases where Insurance Co's reject policy renewals citing arbitrary reasons. For ex: they cannot refuse to renew your policy because you had claims last year. The following are the legitimate reasons for which policy renewals can be refused:

1. If the Policy Holder has crossed the age limit for the policy - maybe 65 or 70. This age has to be clearly and explicitly mentioned in the policy document
2. If the Policy Holder misrepresented facts or provided false details
3. If the Policy Holder did not pay his premium on time and the policy lapsed

In Short, if you are within the Age Limit for the policy, and have submitted all documents truthfully and have paid your premiums on time, the Insurance Company cannot refuse to RENEW your policy.

Right No. 3 - All Claims/Requests Must be Processed Within Deadlines

As per the guideliness set up by IRDA, all Re-inbursement Claim Requests must be processed/paid within 14 to 30 days of submission of all necessary documentation. Usually we will be asked to submit all original bills and receipts, letters from the hospital and doctors along with proof of holding the Insurance Policy to the Insurance Company within the timeline stipulated by the Insurance Co. In the policy it will be mentioned that all claims must be submitted within 'N' days from treatment completion (Usually 'N' will be 7 or 14 days). If the Customer follows the procedure and submits all necessary documents on time, the Insurance Co is supposed to settle the claim within 30 days.

Tip: If the Insurance Co does not settle the claim within 30 days, the policy holder has the right to claim interest on the payout if they have submitted all necessary artifacts on time

In case of Cashless Hospitalization, the amount is settled during the Treatment period itself, so this above Right is not applicable here.

Right No. 4 - Free Look Period

Every Insurance Policy has something called "Free Look" Period during which the policy holder can cancel & return the policy if they are not satisfied. In such cases the Insurance Co has to ensure that the Premium Amount paid by the customer is refunded after deducting any fees/charges as applicable. A point to note here is that, details of the no. of days in the Free Look period as well as the fees payable in case of policy termination during the Free Look period have to be clearly mentioned in the policy document.

In some cases, the Insurance Co may actually delay the approval of your policy until the free look period is over and so by the time your policy is approved, you cannot cancel or return it. This again is wrong.

If the Insurance Co does not refund your amount or does not approve your policy application during the "Free Look" period you can raise a Grievance with IRDA as explained in the previous article.

Some Good News to Wrap Up the Article

Of late, there have been numerous cases in the Health Insurance Space, file by customers against hte Insurance Co's. The Good news is that, there have been Several Judgements where the ruling was in favor of the Insured Individuals and directed the Insurance Co to pay the compensation immediately along with interest and fines.

The IRDA too has been very strict on Insurance Co's that delay claim settlement. Recently, they even pulled up the Government Owned New India Assurance Co for Overcharging of Premiums as well as Delay in Claim Settlements.

At the end of the day, we are not exactly where we must be ideally, but things are changing and changing for good. So, lets hope for the best in the coming years.

Cashless Hospitalization in Health Insurance

In the previous chapter on Health Insurance, I had used the term Cashless Hospitalization. Some of you may have understood what it meant or even used it but there are a few who may not know what it is. Well, the purpose of this article is to understand what Cashless Hospitalization is and how it is useful.

So, lets get started!!!

What is Cashless Hospitalization?

Cashless Hospitalization is a facility using which a person who holds a health insurance policy can get admitted in a hospital and get himself treated without having to pay for all the medical expenses. There are a few things that the insurance does not cover, which the person would have to pay for, but otherwise the insurance company will pay for the rest of the expenses.
Convenient, Right???

How Cashless Hospitalization works?

Let us take an example situation and try to figure out how it works. Let’s say our Uncle Sam has suffered a Heart Attack and needs a Surgery to be done within the next 2 or 3 days. Luckily Uncle Sam has a medical insurance policy and his son is planning to use the cashless hospitalization facility to treat his father. This is how it will happen
Step 1: Uncle Sam’s son contacts the Hospital Reception, explains the situation and inquires about the cashless hospitalization facility.

Step 2: The Receptionist gives him a form to fill-up to request Cashless Hospitalization

Step 3: Uncle Sam’s son fills up the form, signs it and hands it over to the Receptionist

Step 4: The Hospital sends out the details to the Insurance company

Step 5: Officers at the Insurance company validate the documents and the details of the insurance policy. They check if Uncle Sam has enough coverage to pay for the hospitalization. Once they validate they send out a response to the Hospital.

A point to note here is that, the company would send out details of the amount they would pay for the treatment, and the kind of expenses they wouldn’t pay. For Ex: They can say that, Uncle Sams policy covers upto Rs. 2 lacs of treatment and we will not pay for Air Conditioned rooms and food expenses. The rest of the treatment upto Rs. 2 lacs is covered.

Step 6: The Hospital receives the communication from the insurer and shares the news with Uncle Sam’s son.

Step 7: They ask him to sign an agreement that, whatever expenses are not covered would be paid by him before Uncle Sam is discharged

Step 8: After he signs the agreement, the hospital will begin Uncle Sam’s treatment

Step 9: Uncle Sams treatment is over and he is getting discharged today. His son is going to pay the balance amount due to the hospital and take his healthy dad home...

What are the Documents you need for Getting Cashless Hospitalization?

The following are the documents you need for getting or rather using Cashless Hospitalization facility. They are:

1. Identity Proof – like Drivers License, Passport (This is used to validate that the person asking for the feature is indeed the person who is covered by the insurance policy)
2. Insurance Proof – Usually an Insurance Card or a Policy Document (This is used to validate that the person has a valid insurance policy and is currently active as on the current date)
3. Proof of Sickness – Usually a letter or certificate from a Doctor who is treating the patient
4. Proof of Treatment – Usually a letter or certificate from the Hospital that the patient is being treated in their premises

An important point to note here is that, almost all insurance companies and policies have the cashless hospitalization facility. It is better if you confirm with the insurance agent about the availability of this feature before you sign-up for the policy.

Because, better safe than sorry!!!

Do You Have Health Insurance?

Well, this is a million dollar question. Yes and I mean it. According to a recent survey less than 5% of Indians are insured for their health expenditure. Thats actually the good part. The bad part is that 95% of them are either not insured or don’t know what it is.

The purpose of this article is to help people understand what it is and how to use it.

So, lets get started!!!

What is Health Insurance?

Health Insurance is just like any other form of insurance. Let’s take Automobile Insurance for comparison. Everyone who owns a car or a bike knows what it is. Lets say you swerve on the road to avoid a suddenly crossing dog on road and end up bumping the roadside lamp-post. This good deed of yours (trying to avoid running over that poor dog) would cost you thousands of rupees to repair your car. But, fortunately you have car insurance, and the insurance company covers nearly 90% of the expenses and you end up paying a few hundred rupees to get your car fixed “as good as new”

Yes, this is exactly what Health Insurance does. But, instead of your car or bike, its your body that is insured. Whenever you have any health ailment or any disease that requires medical treatment, the insurance company would happily pay for upto 90% of your expenses (Provided you are insured for that much) and you will be “as good as new” after the treatment...

Do we Need Health Insurance?

Yes. 100% Yes. Anyone who asks do we need health insurance needs to read the below paragraph...

Lets say, one fine morning, you wake up and realize that you are having a pain in your chest and it might be a heart attack. You are the only earning member of the family and your wife is a house wife and your kids are in school. You don’t have lakhs of money in your bank to pay for your heart treatment. What would your family do without you? Without the treatment they will be left to fend for themselves without a job and for the treatment you need a few lakhs of rupees which you don’t have either.

You need the treatment because, its a matter of life and death and your family needs you because they depend on you.

What do we do here?

“Health Insurance” is the answer my friend. If you had insured yourself, all this confusion could have been averted. You’d have got your treatment at a good hospital without having to shell out this lakhs of rupees and your family is relieved and happy that you are safe.

An Irony!!!

This is something I have been wondering for quite some time... many of us have bikes and cars and we all have insured them. Cars and bikes are just machines. You can always replace a damaged car or bike with a new one. Something that has just monetary value is insured and the human life and health, something that is invaluable and priceless isn’t treated with as much importance like a car of a bike.
People need to realize that life is precious and we need to ensure that we take good care of ourselves.

How to get Health Insured?

There are many insurance providers who provide health insurance policies. You can contact them and get the insurance. Some of the major insurance providers in the public and private sector are:

Public Sector Players:
1. National Insurance
2. United India Insurance
3. Oriental Insurance Company
4. New India Assurance

Private Sector Players:
1. TATA AIG
2. Chola MS
3. Iffco Tokio
4. Royal Sundaram
5. ICICI Lombard
6. Reliance General
7. HDFC Ergo

What kind of Protection do we need?

We need two important things here:
1. Personal Protection – The case where the policy holder (you and me) is covered for all ailments that involve hospitalization and treatment for the same. The amount that the insurance company would pay would depend on the premium we are willing to pay. This amount can be chosen by the insurer (Again you and me)
2. Family Floater Protection – The case where the family members of the policy holder (Wife, kids, dependant parents) are covered for all medical treatments. Again this would depend on the amount of premium we are willing to pay.
Note: All the above insurance companies i have mentioned in the previous paragraph provide both these protections. I personally suggest you include family floater protection to ensure that all members of your family have health insurance.

Things to Check before Insuring Ourselves

If you have decided that you are going to get yourself and your family health insured, its a great decision and i would like to personally appreciate you for that decision. But, there are a few things we need to check & verify before we sign the insurance papers. They are:
1. Read the whole insurance policy document. Make sure you understand what is covered and what is not.
2. NEVER EVER ASSUME ANYTHING
3. Make sure that the policy covers you and your family
4. Make sure that treatment for accidents is covered in the policy
5. Make sure you read the fineprints (The *s #s and other small prints on the bottom part of the document)
6. Make sure that the coverage includes critical illness cover (Ex: heart attack)
7. Make sure you disclose all existing health conditions of yourself and your family members. Many policies do not cover existing illnesses and not disclosing them can result in no coverage.
8. Find out everything about the claim process (You will need this because; sometimes we won’t have time to do paperwork for cashless hospitalization and hence opt to pay for the treatment. In such cases, we can get the money reimbursed through the claim process)
9. Find out about the claim settlement history of the insurance provider. An insurance company that has a history of rejecting insurance payments is probably not your best option.

To Wrap up, i would like to finish with the words that, health insurance is extremely important and it is always a good idea to have health insurance for us and our family members.

Happy Insuring Yourself!!!