Effect of Room charges capping on other expenses
I have a health insurance policy from National by the name National Mediclaim Policy. There are limits on room charges [25%] , Medical Practitioner's Fees[25%], and Others [ 50%].Within the Room charges there is a per day limit of 1% of Sum Insured . My query is will there be any proportionate deduction in other expenses also in case the room rent exceeds room rent limit of 1% of Sum Insured
You are right. Let me explain by example. If you have a 3 lakh sum insured policy, your room limit would be 3000 per day. Say, you admit in a ward with 5000 room rent + nursing charge per day and the hospital bill comes upto 2 lakhs. Within this 2 lakhs, items on MRP (consumables, medicines) total up to 20,000 and the remaining 1.8 lakhs is services bill (doctor visits, room charges, diagnostic and lab charges etc).
As per proportionate concept, since only 3000 out of 5000 in the room rent is covered, only 60% (3000/5000) will be payable by insurer. So in the above example, 60% of 1.8 lakhs comes to 1.08 lakhs. Add MRP items to it, i.e. 20000, and so the payable amount becomes 1.28 lakhs.
Sometimes, within the bill composition, the services cost exceeds the policy specified limit. That deduction also becomes applicable then. In the above case, if surgeon charges are 80000 out of the 2 lakh bill, whereas as per policy, this cannot exceed 25%, i.e. 50000, then 30000 will be additionally deducted in the claim due to the unbalanced bill.
I hope this clarifies. Do revert if you have a follow-up question.
Thanks Anuj for the prompt response. Would you suggest porting this policy into another insurer where there is no room rent capping. I am a little concerned as this policy is of my parents [ Sr Citizens with PED like Hypertension, Cholestrol] . I have been with National for last 10 yrs and had read an article that its better to stick to same insurer. I don't wish to take any risk of non-settlement of claims by the new insurer saying that PEDs were not correctly disclosed at time of porting. Please suggest . Thanks in advance
Thanks for your follow-up query Rahul.
Your first question had very limited information, so I am not in a position to advise whether you should port or not. If you could share age of your parents, sum insured in your National policy and any claim experience in the last 10 years, it would help me to advise better.
Just to clarify, if you have a sum insured, like 10-20 lakhs, then 1% room rent limit would be a big amount. Similarly, if your parents are upwards of 65 years, your options will be limited. If they're under the age of 65 and the coverage is in the range of 3-5 lakhs, then it leaves more elbow room for me to advise considering a better coverage plan.
Again, ONLY if the current configuration is not optimum, then we can either choose to upgrade sum insured in the current plan itself, or otherwise think about shifting to another plan if feasible.
Please reply back with more information and I will advise to the best of your circumstances.
Hi Anuj , dad is 60 and mom is 56. Sum insured is 5 lacs each . Claims have been very less in last 10 years , mom had cataract surgery for which there was a package rate and there was another incident where I don't exactly recollect the deduction made . Besides , I have also taken a super top up policy from star health for parents for SI Rs 15lacs with a deductible of Rs 3 lacs
Thanks Rahul for sharing more details on your policy.
Good you have a super top-up policy. The one that Star has, at 15 lakhs sum insured would be the Gold plan with Single Pvt Ward eligibility. 3 lakh deductible option is also good.
I think you should try and match the policy benefits in base policy as well as the top-up policy. If you have both from same insurer, you can enjoy cashless in both policies in single admission should the sum insured in base policy expire during admission. If base and top-up are from different insurers, then you'd have to pay from pocket first when the sum insured in base exhausts, and then claim it from 2nd insurer and wait to be paid.
Given that affordability of room limit in National policy will deteriorate over time and also considering you parents' age, I think you have a good chance to port now. I would suggest you should first prefer porting to Star Health's Family Health Optima (FHO) or the Comprehensive Health (CHI) plan. FHO may not agree for porting given the medical history, but it's cheaper than CHI any given day. Underwriting in CHI is little relaxed as it's a premium product, so it should be your backup. If Star doesn't accept porting request in any of these plans, then you've several other insurers to consider who have pvt ward limit or no room rent capping. That's a separate discussion infact.
But make sure you without fail mention all the Pre Existing Medical Conditions (PEDs) while porting. Be very precise in giving the information, history prior to National policy, history of claims in National policy and any other medical conditions for which claim was not filed but were diagnosed during the last 10 years... all need to be declared.
Porting is seamless is these precautions are taken care of. If you need more specific advice, I am reachable on firstname.lastname@example.org
Many thanks Anuj . Let me get the medical history sorted and then approach star as suggested by you. In case of further queries, I shall definitely reach out to you . Many thanks for all your advice .