Potential problems with Single Private A/C Room limit
Let's say that I have a policy that has NO room-rent limit. However, there is a limitation of Single Private A/C room in hospital charges. I wanted to know, potentially, what can go wrong in such cases? Also, what are the odds of that happening practically?
I am asking this because Star Comprehensive has this clause.
In Star Comprehensive, the room limit is defined as a Single Pvt Ac room. There are at least 20 insurance products in the market that define room limit as Single Pvt ward.
The thing that's left unsaid in the policy wordings is that it is single Pvt Ac ward of the lowest category.
Let me explain using an example.
In any decent size hospital, there are multiple types of private wards with single patient occupancy. There would be a single private room in the hospital or an entry-level Pvt ward, which normally has a small area and an attender bed. It may or may not have an attached toilet facility. Then there would be a deluxe ward a step above. Such a room will be bigger in the area and may have some additional facilities.
Top-end Pvt wards in hospitals are generally called ultra-deluxe rooms or VIP rooms. These may have great views, bigger spaces, high-end medical infrastructures such as electronically operated beds, and swanky private meeting areas for visitors.
Keep in mind that cost of treatment goes up by 20-30% as you opt for high-end wards.
Therefore, for people with a Single Pvt room limit defined in the policy, always check with the hospital for the cheapest single ward.
Now you may ask me, how will the insurer know which Pvt ward is assigned to the patient because of this variety. Good question.
If it is cashless admission, due to existing tie-up between insurer and hospital, your insurer knows which one is the basic Pvt ward and its rental in the hospital. For non-empaneled hospitals, general insurers have hospital tariffs already available with them from previously processed claims, or at times insurers ask patients to submit the hospital's room tariff chart.
Another question coming to your mind would be, what happens when you opt for any Pvt ward that costs higher than the entry-level Pvt room in the hospital? In that case, the insurer will deduct money in your claim using the principle of Proportionate deduction (PD). They will check the difference of room rent of ward you admitted in and rent of entry-level Pvt room to proportionately deduct claim amount.
Happy to answer any follow-up questions.
That was a very detailed answer. Thanks.
What happens in the specific case of Star Comprehensive? Do the Single AC Room charges in the hospital mentioned here cover the cost of the 'Ultra deluxe / VIP rooms'?
Also, in case we go for a policy that has no 'Room Category Limit', say, ICICI Lombard Health Shield, do we get to choose ANY type of room we want (paneled or empaneled hospitals), as long it doesn't exceed SI?
I have purchased Optima Secure health insurance from HDFC Ergo. There is no room rent capping, but there is room category capping of Single AC private room. So, i guess, if one gets hospitalized in s deluxe room, they will deduct the claim amount proportionately?
Is it better to port to Niva Bupa?
But then the claim settlement ratio of HDFC Ergo is much better than Niva Bupa. Please advise.
So if a policy says "Covered up to any room except suite or higher category", would that mean that one is eligible for the higher category "private single AC room".
Thanks to everyone responsible for raising and responding to this important topic
The answer is No to your first question and Yes to your second question
In that case, for someone going for a cover of ~20lacs (10 Base + 10 Super Top-up), does it even make sense to consider 'Star Comprehensive' (which has a Single Private A/C Room clause) over Lombard's Health Shield (which doesn't have no Room Rent/Category clause). I ask this because the former adds a lot of unpredictability in terms of service expectations and also increases the odds of bearing unhidden costs. ....................................................................................
Having said that, I find it really odd that Star Health would put such a limit in their flagship policy. Would love to know your thoughts on this as well.
Your observation is right Shubham. ICICI Lombard has a much better product vs Star as in it reduces the uncertainties related to claim in future.
Every insurance product has a target market and they try to optimize for it. Some products have a premium appeal, some are meant for customers seeking affordable cover. All these considerations go into underwriting and product design. There is never a right or a wrong answer in product design, it's all about target customer profiles they are going after. You are a more evolved insurance buyer, you've asked several questions to build your nuanced understanding of the market, so some products like Star Comprehensive won't make sense to you as you can discover products who deliver same or more value at comparable price-points.
Makses sense. Thanks!
If you compare the pricing of different policies then Star Comprehensive is actually expensive. So I agree with Shubham that it makes no sense to go for it. Star should reevaluate this room limit situation in Comprehensive plan.