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ICICI Lombard Health AdvantEdge

Fair
4.9
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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HDFC Ergo Optima Secure

Expensive
4.6
Beshak Rating

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No room rent limit

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All day care procedures

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2X cover from Day 1

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Niva Bupa Aspire (Titanium+)

Fair
4.6
Beshak Rating

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No room rent limit

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All day care procedures

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Fixed premium till you claim

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Niva Bupa ReAssure 2.0 (Titanium+)

Fair
4.5
Beshak Rating

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No room rent limit

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All day care procedures

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Fixed premium till you claim

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Tata AIG MediCare Premier

Fair
4.5
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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Niva Bupa ReAssure 2.0 (Platinum+)

Fair
4.5
Beshak Rating

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No room rent limit

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All day care treatments

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Premium is fixed until you claim

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Niva Bupa Health Companion

Fair
4.5
Beshak Rating

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No room rent limit

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All day care procedures

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Health check-up from day 1

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Reliance General Health Gain (Power)

Fair
4.4
Beshak Rating

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No room rent limit

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All day care procedures

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Reduced PED waiting period

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Reliance General Health Infinity

Fair
4.4
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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HDFC Ergo Optima Restore

Expensive
4.4
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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Tata AIG MediCare

Fair
4.3
Beshak Rating

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No room rent limit

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541 day care procedures

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Consumables coverage

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Aditya Birla Activ One (NXT)

Economical
4.3
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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Aditya Birla Activ Assure Diamond

Economical
4.2
Beshak Rating

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No room rent limit

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586 day care procedures

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Consumables coverage

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Star Health Assure

Fair
4.2
Beshak Rating

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Any room except Suite

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All day care procedures

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Consumables coverage

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Royal Sundaram Lifeline (Supreme)

Economical
4.2
Beshak Rating

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No room rent limit

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All day care procedures

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Organ donor expenses cover

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Star Health Comprehensive

Expensive
4.2
Beshak Rating

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Any room except Suite

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All day care procedures

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Consumables coverage

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Star Health Family Health Optima

4.2
Beshak Rating

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Any room except Suite

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All day care procedures

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Consumables coverage

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Royal Sundaram Multiplier

Economical
4.2
Beshak Rating

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No room rent limit

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All day care procedures

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Organ donor expenses cover

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Aditya Birla Activ Fit (Preferred)

Fair
4.2
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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Aditya Birla Activ Fit (Plus)

Fair
4.2
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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AB Activ Health Platinum (Premier)

Expensive
4.2
Beshak Rating

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No room rent limit

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586 day care treatments covered

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Day 1 coverage for few PEDs' management costs

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AB Activ Health Platinum (Enhanced)

Fair
4.1
Beshak Rating

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No room rent limit

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586 day care procedures

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Cashless home treatment

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Bajaj Allianz My Health Care

Expensive
4.0
Beshak Rating

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Single Private AC Room

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399 day care procedures

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Organ donor expenses cover

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Manipal Cigna PH Prime (Protect)

Fair
4.0
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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Manipal Cigna PH Prime (Advantage)

Expensive
4.0
Beshak Rating

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No room rent limit

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All day care procedures

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Consumables coverage

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Bajaj Allianz Health Guard (Gold)

Economical
4.0
Beshak Rating

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No room rent limit

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399 day care procedures

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Organ donor expenses cover

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Bajaj Allianz Health Guard (Platinum)

Fair
3.9
Beshak Rating

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No room rent limit

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399 day care procedures

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Organ donor expenses cover

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Manipal Cigna ProHealth (Plus)

Fair
3.9
Beshak Rating

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Any room except Suite

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546 day care procedures

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NCB up to 200%

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Manipal Cigna PH (Accumulate)

Expensive
3.9
Beshak Rating

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Any room except Suite

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546 day care procedures

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NCB up to 200%

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Manipal Cigna ProHealth (Protect)

Fair
3.9
Beshak Rating

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Any room except Suite

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546 day care procedures

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NCB up to 200%

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Care Insurance Care Supreme

Fair
3.8
Beshak Rating

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No room rent limit

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All day care procedures

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NCB up to 600%

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Care Insurance Care

Fair
3.3
Beshak Rating

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Single private AC room

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541 day care procedures

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Consumables coverage

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New India Floater Mediclaim

Economical
2.0
Beshak Rating

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Up to 1% of SI per day

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139 day care procedures

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Spouse's mid-term inclusion

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Notes

1- The health insurance data was last updated in September 2023. All data has been sourced from product brochures, policy wordings, prospectus, public disclosures (Q1, FY 2023-2024), insurer websites, and the IRDAI website. 

2- The Claims Settlement Ratio data is taken from NL-37, insurer public disclosures (Q1, FY 2023-2024). It is calculated by dividing the number of claims settled by the sum of claims outstanding at the beginning of the year and claims reported during the year.

3- The data related to claim complaints and policy purchase complaints is taken from NL-45, insurer public disclosures (Q1, FY 2023-2024).

4- The Solvency Ratio data is taken from NL-26, insurer public disclosures (Q1, FY 2023-2024).

5- The data related to claims settled within 30 days is taken from NL-39, insurer public disclosures (Q1, FY 2023-2024).

6- The Claims Incurred Ratio data is taken from NL-4 and NL-5, insurer public disclosures (Q1, FY 2023-2024). It is calculated by dividing the Net Claims Incurred by the Net Earned Premium.

7- For now, we have considered the most comprehensive plans from leading insurance companies. We will keep updating the product pages with new plans in the coming days.

8- We have rated only those plans that can be serviced by individual advisors. This is because of our strong belief that health insurance customers need professional assistance from individual advisors before and after purchase. We do not recommend and hence do not rate direct-to-customer health insurance plans or plans where there aren't enough advisors available to service. 

9- Affordability assessment of plans: 

  • The affordability of comprehensive plans is assessed using premiums for a family of two adults (30 years old) and one child (1 year old) residing in Zone 1, opting for a cover of ₹10 Lakhs. And, the premiums are as of 30th September 2023.
  • The affordability of Care Freedom Plan is assessed using premiums for a 30-year-old male residing in Zone 1, opting for a cover of ₹5 Lakhs. And, the premium is as of 30th September 2023.
  • The affordability of Acko Platinum Health Insurance is assessed using premiums for a family of two adults (30 years old) and one child (1 year old) residing in Zone 1, opting for a cover of ₹25 Lakhs. And, the premium is as of February 2024.
  • The affordability of ICICI Lombard MaxProtect (Premium) is assessed using premiums for a family of two adults (30 years old) and one child (1 year old) residing in Zone 1, opting for a cover of ₹1 Crore. And, the premium is as of February 2024.
  • The affordability of Aditya Birla Activ One (VIP+) is assessed using premiums for a family of two adults (30 years old) and one child (1 year old) residing in Zone 1, opting for a cover of ₹1 Crore. And, the premium is as of March 2024.

10- We have considered the Inflation Protection benefit under Acko’s Platinum and Standard Health Plan instead of the No Claim Bonus Benefit.

11- The product benefits section is based on a sum insured of ₹10 Lakhs and only highlights the top benefits and features of health insurance plans. 

12- Only those hidden and special conditions that apply to the benefits and features we have considered are included on the product pages. 

13- The product pages only include the most significant specific exclusions under each plan, which we've simplified for better understanding.

14- The product pages do not include any generic terms, conditions, or exclusions (those that are the same and apply to all health insurance plans).

15- If the policy wording, brochure, or prospectus states that a benefit/feature is available with a specific plan but it is not available online when generating the premium quote, we have not considered that benefit/feature to be available with the plan.

16- The response time on Twitter was calculated using a sample set of tweets from February 2023 to August 2023 (analyzed in September 2023).

17- The metrics like claim complaints, policy purchase complaints, response time on Twitter and toll-free are not related to a specific product but are related to the overall performance of the insurance company.

18- The network hospitals' data was last updated on 5th March 2024.

What is Health Insurance?

Health insurance is a type of insurance policy that covers costs related to hospitalization resulting from illnesses, accidents, or injuries. It safeguards you against unforeseen medical expenditures, which could otherwise cause significant financial stress. It acts as a protective shield for savings and healthcare, allowing you and your family to live a happy and fulfilling life. 

How Does Health Insurance Work?

A health insurance policy offers coverage for medical expenses in exchange for regular payments, known as premiums. With a health insurance policy in place, you can make multiple claims in a policy year up to the cover amount. It, however, opens up to a full cover in a phased manner. 

For the initial 30 days, it does not cover any treatment for or related to any medical condition, except for accidents. For pre-existing diseases, i.e., any condition, ailment, injury, or disease diagnosed or treated by a doctor 48 months prior to the date of issue of your health insurance policy, there is a waiting period of 2-4 years applicable.  A waiting period of 24 to 48 months is also imposed on specific medical conditions and treatments.

Why Do You Need Health Insurance?

Here are 5 reasons why health insurance is absolutely necessary - 

Medical costs are skyrocketing: 

  • With advancements in medical technology and the onslaught of new diseases, medical expenses are only bound to increase. The only thing that can help us afford the increasing medical expenses is a health insurance policy.  

Health conditions may need expensive long-term treatments: 

  • It has become possible to cure diseases that were once considered incurable - all because of the developments in medical technology. But, the cost of such treatments is so high that it is almost impossible for a normal person to afford them. Health insurance is the only thing that will ensure financial protection in such situations.

Your healthcare fund will not suffice: 

  • Many people depend on their savings or a healthcare fund for medical treatments and emergencies. While such a fund definitely is useful, it shouldn’t be treated as a replacement for health insurance. The treatment and surgery costs today could cost a fortune and a healthcare fund will not be enough to deal with them.

You may not get health insurance later: 

  • The insurance company can require you to undergo certain medical tests when you apply for health insurance. For instance, insurance companies may ask you to undergo a medical checkup if you’re over 45 years old. The results of these tests will decide if you’ll get health insurance or not. Not to mention the fact that as you grow older, your vulnerability to health conditions rises. In turn, the probability of your health cover application being denied rises too. 

Tax benefits: 

  • Payments made towards health insurance premiums are eligible for tax deductions under Section 80D of the Income Tax Act. You can get deductions for the health insurance premium paid for yourself, your spouse, your dependent children, and your parents. 

When Should You Buy Health Insurance?

Well, you should get health insurance before you get into an accident or contract a serious health condition that necessitates a major hospitalization. Insurance companies find it risky to cover someone who has a lifestyle disease since this will lead to more hospitalizations, and hence, more claims. They may either charge an extra premium or levy some additional conditions. In a nutshell, you should be covered by health insurance as soon as you are born till you die - either through your parent's policy, employer's policy, spouse's policy, or your own policy.

What Does Health Insurance Cover?

Health insurance provides comprehensive coverage for hospitalization expenses. Here’s a quick overview of some of the expenses covered by a standard health insurance policy - 

Inpatient hospitalization:

  • Inpatient care refers to health care you get upon admission to a hospital. In order for health insurance to cover inpatient charges, the hospital stay must be longer than 24 hours. Any treatment needing less than a 24-hour hospital stay is not covered by health insurance unless it is included under Day-care treatments. Inpatient expenses include the room charges, ICU charges, doctor fees, specialist or consultant fees, costs of surgery, etc. payable to the hospital.

Pre and post-hospitalization costs:

  • Medical expenses like doctor consultations, medicines, and diagnostic tests incurred for the injury or illness before you are hospitalized are covered under health insurance. These are called pre-hospitalization expenses. Similarly, after being discharged from the hospital, any follow-up check-ups, consultations, medicines, etc. you undergo are called post-hospitalization expenses. These are covered too.

Organ donor expenses:

  • In the case of an organ transplant, the costs of hospitalization and the donor's surgery are covered by most health insurance policies.

Domiciliary hospitalisation:

  • Many health insurance policies also cover domiciliary hospitalization i.e. hospitalization at home, where a hospital cannot be used for treatment because of these reasons -
    • Non-availability of beds in the hospital
    • When the patient is so ill or injured that it is impossible to move them to the hospital 

Day care treatment expenses

  • These include treatments that are completed in less than 24 hours at a hospital or a day care centre under general or local anaesthesia. Health insurance plans cover the expenses of day care treatments too.

What Does Health Insurance Not Cover?

Several types of costs aren’t covered by a standard health insurance policy. Let’s have a look - 

Permanent Exclusions:

  • The insurance company will NEVER cover these costs. These are of the following types: 
    • Standard Permanent Exclusions: These are listed by the IRDAI and must be imposed by every insurance company. These include - 
      • Investigation and evaluation: Admission to a hospital only for observation or monitoring purposes. 
      • Rest cure, rehabilitation and respite care: Expenses incurred for admission to any facility primarily for bed rest - where no active treatment is carried out.
      • Obesity/weight control: Any treatment or surgery done for weight control or obesity. 
      • Change of gender treatment: Treatment carried out to change the characteristics of the body to those of the opposite sex.
      • Plastic/cosmetic surgery: Any treatment/surgery carried out to alter body characteristics or your appearance.  
      • Profession in hazardous or adventure sport: Any treatment expenses incurred while you’re working as a professional in adventure activities like river rafting, mountaineering, scuba diving, horse racing, etc. 
      • Breach of law: Expenses incurred towards the treatment of a person who has committed or has attempted to commit a breach of law with criminal intent.
      • Excluded providers: Getting treatment from a medical practitioner or in a hospital that is excluded by the insurance company. 
      • Unproven treatments: Surgeries, medical procedures, or treatments undergone that are not proven to be effective.
      • Narcotics: Any treatment conducted for addictive conditions like alcohol addiction, drug usage, etc.  
      • Maternity expenses: Pre/post-natal costs, hospitalisation expenses incurred during childbirth, etc. 
    • Additional Permanent Exclusions: The insurance company may also impose certain additional exclusions, which are permanent, if you have a history of certain diseases and it finds them risky to cover. However, insurers are limited to a list of illnesses listed by the Insurance Regulatory and Development Authority of India (IRDAI) for which they can apply a permanent exclusion. They cannot apply permanent exclusions to illnesses or diseases outside this list.
    • Temporary Exclusions/Waiting Periods: The health insurance policy will not cover all health conditions from day one. You’ll have to wait for a specified period of time to avail of coverage for the same. This span of time is known as a ‘waiting period’. The main types of waiting periods include - 
      • Initial waiting period: All medical conditions except accidents are excluded for the first 30 days after the policy is issued. Meaning, you won’t be able to make a claim for any hospitalisation for 30 days - except in case of accidents. 
      • Pre-existing disease waiting period: A pre-existing condition is any medical condition or illness that you have had in the 48 months (4 years) before issuance of the policy. There is a standard waiting period of 2-4 years for pre-existing conditions. The policy will not cover any expenses related to your pre-existing condition during this period. 
      • Specified disease/ procedure waiting period: Every insurer will provide a specific list of medical conditions (apart from your pre-existing diseases) that will have a waiting period of around 2-4 years. This waiting period will be applied regardless of whether or not you have had those diseases in the past. This is based entirely on the insurer and not on your health. 

What Are The Types of Health Insurance?

Health insurance plans can be of the following kinds - 

Individual Health Insurance

  • Individual health insurance covers one person under a single policy. One of the biggest pros of individual health insurance is it shields one family member's coverage from another, ensuring that a claim by one member will not impact the coverage of other members.  

Family Floater Plans

  • A family floater covers your multiple family members under the same plan. The cover amount essentially 'floats' among all members covered under the floater plan, and is available to any and all of them! This makes them less complicated and easier to manage.

Multi-Individual Health Insurance

  • This plan gives you the best of both worlds - a family floater and an individual health cover. You can insure multiple family members under the same plan while retaining individual coverages for all of them. 

Senior Citizen Health Insurance

  • These plans are specifically curated for people who are above the age of 60. They usually may not require medical tests but can come with many limitations and restrictions like copays, room rent limits, etc. 

Critical Illness Insurance

  • Critical illness insurance helps you and your family deal with the financial impact of a severe disease. It pays a fixed sum of money if you're diagnosed with an illness that is listed in the policy. This money can be used to take care of the additional expenses that you may have to incur as a result of the disease.

Group Health Insurance

  • These health insurance plans cover groups of people, generally with a common purpose, like account holders of a bank, employees of an organization, registered users of a mobile app, etc. They come with less documentation and typically no medical tests. However, they may have lots of limitations and will be valid till you’re a part of the group. 

Topup and Super Topup Plans

  • These are basically extensions to your base health insurance plan. They come with deductibles i.e. an amount after which the topup/super topup kicks in.
    • A topup plan’s deductible is calculated on every single hospitalisation. So, it becomes active and starts paying only if the expenditure on one hospitalisation crosses the deductible limit. 
    • A Super Topup’s deductible, on the other hand, is calculated based on the sum total of all hospitalisation expenses incurred during the year. 

Standard Health Insurance Plan: Arogya Sanjeevani 

The IRDAI has mandated every insurance company to offer Arogya Sanjeevani, a basic and standard indemnity health insurance plan for both individuals and families. It was launched by the IRDAI on 1st April 2020. The main motive behind introducing this plan was to make health insurance more accessible, easy on the pockets, and less confusing for buyers. Here’s how it works - 

Type of plan:

  • The Arogya Sanjeevani Plan can be bought as an individual cover or a family floater.

Sum insured: 

  • This varies across insurers. Typically, it ranges from Rs 50,000 to Rs 10,00,000.

Policy term:

  • The policy span lasts for one year max.

Entry age:

  • Adults - 18 to 65 years.
  • Children - 3 months to 25 years. Children between 3 months to 18 years can be covered under a family floater only. Children between the ages of 18-25 years can take the cover either on an individual or a floater basis.

Who can be covered?

  • Yourself, your spouse, dependent children, parents, and parents-in-law. The total number of members you can cover under one policy may vary across insurance companies.

How Much Health Insurance Should You Buy?

Remember that health insurance is a protective shield for a life time of medical expenses. Therefore, it should be enough for today and also for the future. If you're less than 40 years old, remember that you are pre-booking a good product today, that may not be available later in the same shape or form, due to age or health-related reasons later. 

But can’t you upgrade later? Well, it gets tricky when you're older, around 55 or 60. If you've had a health issue or someone in your family got sick, your chances of upgrading your insurance drop a lot – from 90% to about 20%. Leaving this decision for the future doesn't really make sense. So, how much health insurance should you really buy?

So, taking linear medical inflation of 6%, if 3 lakh rupees seems like a good amount to have for medical expenses right now, you would actually need at least 16 lakh rupees in 30 years. If you're getting a health insurance plan that covers both you and your partner, you should think about getting coverage worth 30 lakh rupees – that's double the individual amount. 

Things To Keep In Mind Before Buying Health Insurance

Here are 8 things you should be mindful of when investing in a health insurance plan - 

⏩Have enough coverage for your old age: 

  • Owing to rapid medical inflation, the cover amount you feel might suffice today will not be enough for the future, when you’re older and more susceptible to health problems. It might also get difficult to upgrade your cover because of these reasons.

Steer clear of room rent limits:

  • Most health insurance plans with a cover of less than Rs 5 Lakhs come with room rent limits. If you choose a hospital room with a rent that is more than what you’re eligible for, the insurer will deduct the difference in room charges and proportionately deduct all associated medical costs.

Avoid limits on specific treatments/procedures: 

  • Some insurance companies may levy limits on specific diseases or treatments. If you buy a policy with such limits, you may have to pay a large amount of money yourself, despite having an adequate cover amount. 

Avoid copayment clauses:  

  • A copayment is essentially a cost-sharing aspect, where you bear a percentage of the approved claim amount, while the insurer takes care of the rest. Such clauses can lead to big out-of-pocket expenses. 

⏩Ensure that all day care procedures: 

  • These are medical procedures or surgeries that required a long stay at the hospital but can now be completed in less than 24 hours because of advancements in medical technology - are covered under the policy.

⏩Make sure that organ transplant costs are covered since these can get pretty high:

  • Health insurance will cover the organ receiver’s hospitalisation expenses if you ever require an organ donation in the future. But, it won’t cover the organ donor’s expenses and you may have to pay for all these expenses out of your pocket. If you opt for an organ donor cover with your health insurance that covers the expenses of the donor as well, these out-of-pocket expenses can be avoided. 

⏩Restoration Benefit:

  • Medical costs are on the rise and a single major hospitalisation can exhaust a huge chunk, if not all, of your cover amount. This is especially worrisome if your loved ones are covered by a family floater. You can replenish your cover with the restoration benefit. Just make sure -
    • It triggers on partial exhaustion of the cover, not just complete exhaustion.
    • It is inbuilt with your base plan, so you don’t have to pay extra.
    • It kicks in for both related and unrelated conditions. 
    • The restoration is up to your base cover and not just the claim amount you’ve used.

⏩Coverage for non-medical expenses:

  • Make sure that non-medical expenses like gloves, syringes, cotton swabs, gauze, bandages, etc. are covered by the plan or by an add-on. Even though these seem like ancillary costs, they can add up very quickly and become a huge expense. 

How To Make A Claim Under Health Insurance?

Health insurance claims are of two types -

Cashless Claims: 

  • These can be made if you get treated at a network hospital. The insurer/TPA settles the bills with the hospital and you don’t have to pay money upfront.

Reimbursement Claims: 

  • You pay the medical bills upfront and then claim the same from the insurer.

When you know that hospitalisation is on the cards, choose a hospital (preferably one that is on your insurer’s network and offers cashless claims) and choose a room based on the room rent limit mentioned in your plan.

Cashless Claim Process

  • Confirm that the hospital offers cashless claims because dynamics can change. It’s best to be completely sure about such aspects.
  • Get a list of the documents you’ll need to submit. Also, check if there are any sub-limits in your policy to assess the out-of-pocket expenses you’ll incur.
  • Take pre-authorization from the insurance company. This is the initial approval of your medical costs. For this, you need to inform the hospital insurance desk about the plan you own, submit any relevant documents (policy copy, KYC, medical reports, etc.), and fill up and sign a claims form. The hospital’s insurance desk will take this ahead with the insurer/TPA.
  • Keep in mind that the insurance desk may not work 24x7. So, depending on these circumstances you might need to pay an advance to get the admission or delay the discharge if the final approval is delayed. Some hospitals may ask for a deposit even in cases where cashless is approved. Keep emergency money handy always.
  • If the treatment cannot wait for pre-authorization, the hospital might ask for an advance payment. This advance is later refunded (fully or partially) when the insurance company approves the cashless claim request.
  • Make sure you process the paperwork 3-4 days in advance in case of planned treatment. If it’s an emergency, have it done within 24 hours of hospitalization.
  • Once the pre-authorization form is submitted, you’ll be able to track the progress. Do this dedicatedly. Answer all questions posed by the insurer promptly.
  • Keep soft copies of your documents since the insurance company may ask for the originals. 
  • Track your billing every day and bring up any discrepancies. Also, keep a thorough record of pre-hospitalisation expenses as these will have to be claimed separately. Choose to buy medicines at the hospital counter since they’ll be covered under cashless too.
  • Once the discharge process is done, follow up with the hospital desk for your final paperwork submission (including the final bill and discharge summary). You may be asked to also submit any pending documents.
  • The claim process will move ahead once you get the final approval from the insurance company, which can take around 2-6 hours.
  • The insurer’s final communication will either be an approval or rejection of the claim in the form of a claim settlement summary. This will contain all details of the claim settlement.
  • If your claim is approved, it will have an account of the approved and unapproved expenses.
  • Read the summary carefully to understand what’s not approved. You may have to take care of copays, proportionate deductions, consumables, etc.
  • Don’t forget - 
    • To get your initial advance adjusted in this calculation.
    • Any deposits that you may have made to the hospital can be claimed as a refund later.
    • If your claim had deductions due to a shortage of the available sum insured or limits/exclusions or co-pays in the policy, you can claim the remaining amount from another health insurance policy on a reimbursement basis.
    • Every cashless claim has a reimbursement component for pre-hospitalization and post-hospitalization expenses. Claim these expenses.

Reimbursement Claim Process

Reimbursement can be for the entire treatment, only pre and post-hospitalization expenses in case of cashless, or when one policy is used for a cashless claim and the remaining unclaimed amount is claimed through reimbursement.

  • Inform the insurer about the hospitalization within 24 hours of the admission. Ask them about the timeline for claiming the reimbursement and the documents you will need to submit. Start gathering them.
  • The most important bit of the claim process is the documentation. 
    • Keep all documents from the date of diagnosis to recovery, including doctor consultations, prescriptions, bills, receipts, reports (including films), X-Ray or MRI films, pharmacy bills, and everything else in a secure folder.
    • Create an Excel sheet of all the medical expenses, right from the first doctor consultation to medical tests, hospital bills, medical test reports, doctor prescriptions after discharge, receipts, and medicine bills throughout.
    • Organize and number these documents for ease of submitting them.
    • Fill up the claim form carefully after reading what is asked and providing all the details correctly.
  • You will need to submit documents such as -
    • Health card or policy copy
    • Photo ID of the insured
    • Claim form, filled and signed. 
    • All prescriptions for medicines, medical tests including prescriptions from the first doctor you visited.
    • All original pharmacy bills 
    • All original test reports, including films & CDs 
    • Original hospital bill with patient details including an itemized bill
    • Original discharge summary from the hospital 
    • All other original bills before the hospitalization associated with your treatment.
    • Bank account details of the policyholder which can be provided through a cancelled cheque for NEFT transfer of your reimbursement.
    • FIR or a medico-legal certificate or a summary of how the accident happened may be required in case of an accident.
  • Make sure you keep copies of all the documents you submit to the insurer.
  • The insurer may have additional requirements or questions. Answer them promptly to avoid delays.
  • The insurer will typically credit your reimbursed amount to the bank account you provided the details of. They will also send you a summary of any deductions they’ve made. Go through this carefully and raise any concerns you may have.

10 Little-Known Causes For Disputes In A Health Insurance Claim

Health insurance claim got denied or disputed? Here’s what might have happened - 

Specified disease/procedure waiting period: 

  • There is a waiting period for a list of specified diseases (apart from pre-existing conditions) like slipped discs, knee replacement surgeries, etc. that ranges from 2-4 years. If your policy has not completed this time frame, expenses related to these treatments will not be covered.

Room rent limit & proportionate deductions

  • Having a financial limit for room rent charges can be devastating for your wallet. Many health insurance policies with a sum insured of less than 5 Lakhs have a room rent limit. If you choose a room beyond this limit, you pay the difference in the room charges and a proportionate deduction for all the remaining expenses.

Changes in the policy benefits/conditions

  • IRDAI allows insurers to change their policy benefits, conditions, pricing, etc. Insurers can also stop a plan completely and migrate you to another plan, which may have different conditions.

‘Medically necessary’ hospitalization

  • A health insurance plan only pays for a necessary hospitalization. If any hospitalization or treatment is not found to be medically necessary by the insurer, the costs of the same will not be covered.

Active treatment

  • Hospitalization for diagnostic or monitoring purposes is not covered under health insurance.

Reasonable & customary clause

  • With the reasonable and customary clause, insurers protect themselves from excessive hospital billing. Insurers measure reasonable charges by comparing the costs levied by a similar-grade hospital in the same locality. And, the insurer can refuse to pay the overcharged amount and may instead pay only the standard rates charged by similarly graded hospitals in the same area if your hospital charges significantly more for a particular treatment than other hospitals in that same geographic area. 

Being careless about the proposal form

  • Health insurance is an agreement of utmost good faith. The insurer agrees to take the risk of your future healthcare expenses and expects you to furnish honest, accurate information when you buy the policy. If they find out that the info is false, forged, or incomplete, the claim can be rejected and your policy may even be cancelled. 

Details not added or delayed by the employer

  • In the case of a company health insurance policy, employers or their HR team can miss adding your name or family's name. This can lead to disputes when you make a claim.

Incorrect information provided to the doctor on admission

  • Make sure that the medical history of the patient is provided honestly and diligently to the hospital and doctor during admission. Any misses can jeopardize the claim.

Lack of adequate claim documentation

  • Ensure you possess and submit all the documentation that is needed for filing a claim like doctor prescriptions, medical reports, invoices, payment proofs, etc. If you don’t have these, the claim can be denied or disputed.

Renewing Your Health Insurance

While health insurance policies provide lifetime coverage for hoapitalization and associated expenses, they need to be renewed every one year, two years, three years - depending on the policy term you opt for. To keep your coverage and benefits intact, you need to renew the policy on time. If you don’t renew it on time, you’ll be given a grace period to do so. If you still don’t renew it during this second window, your policy will lapse and the benefits will cease.  

Things To Evaluate While Renewing Your Health Insurance

When renewing your policy, assess these things -

  1. Enhance your cover amount if you find the need to do so. Medical inflation has been increasing at an unprecedented speed and it’s important to keep up with it since your health coverage will ideally last a lifetime.
  2. Add/remove family members if there have been births, weddings, deaths, changes in relationships, etc.
  3. Research the various riders (add-ons that you buy at an extra price to broaden your coverage) available with the policy. Some insurance companies allow you to opt for various riders, such as a critical illness rider, accidental disability rider, etc. These riders provide additional financial protection in certain circumstances. 
  4. Go through the T&Cs to the finest detail. Insurers can change policy terms and conditions and you should be aware of every tiny alteration.
  5. Consider porting to a new plan offered by a different insurer if you’re unhappy with your current policy or find that it no longer fits your needs. You’ll have to inform the insurance company 45 days before your health insurance renewal date.

Health Insurance Portability And Migration

After you own a health insurance plan, there might arise a situation wherein you aren’t happy with it. Maybe you aren’t completely satisfied with the services provided by your current insurer. Maybe you’ve found a plan with better features. In this case, you can either port or migrate your plan. Let’s see what these terms mean.

Portability:

  • You shift your plan to another health insurance plan offered by a different insurer. For this, you’ll have to inform the insurer 45 days before your plan’s renewal.

Migration

  • You shift your plan to another similar health insurance plan offered by the same insurer. For this, you’ll have to inform the insurer 30 days before your plan’s renewal.

When porting or migrating your plan, you can transfer the cover amount, the waiting period credit (for pre-existing and other diseases), and any accrued no-claim bonus. You should, however, note that there can be both positive and negative consequences of migration or porting a health insurance. You might end up paying a much larger premium or the insurer might impose waiting periods on certain diseases. There might also be other limitations/ exclusions imposed. Worse, your application for portability or migration could get declined too. So, ensure you’re aware of all these consequences before going ahead.

Health Insurance Tax Benefits u/Section 80D 

The health insurance premiums you pay every year are eligible for tax deductions under Section 80D of the Income Tax Act of India. If you’re an individual or a member of a Hindu Undivided Family, you can get tax deductions on the premiums paid for health insurance for yourself, your spouse, your dependent children, and your dependent parents. The maximum deduction you can claim depends on your and your family members' age -

Individuals and Parents below 60 years: 

  • Up to Rs 50,000
    • Up to Rs 25,000 for you, your spouse, and your children.
    • Up to Rs 25,000 for your parents, who are below 60 years.

Individuals below 60 years and Parents above 60 years: 

  • Up to Rs 75,000 if you, your spouse, and your children are below 60 years and your parents are above 60 years.
    • Up to Rs 25,000 for you, your spouse, and your children.
    • Up to Rs 50,000 for your parents, who are above 60 years.

Individuals and Parents above 60 years: 

  • Up to Rs 1 Lakhs if you, your wife, and your parents are above the age of 60 years.
    • Up to Rs 50,000 for you, your spouse, and your children.
    • Up to Rs 50,000 for your parents, who are above 60 years.

Members of Hindu Undivided Family (HUF)

  • Up to Rs 25,000 for a health insurance policy taken for any members of the HUF if their age is below 60 years.
  • Up to Rs 50,000 for members above 60 years. 

HUF consists of males descended from a common ancestor, their wives, and unmarried daughters. 

Non-Resident Individuals (NRIs)

  • Up to Rs 25,000 for self, spouse, and dependent children. 

Additional Rs 25,000 or parents up to 60 years. For parents above 60 years, up to Rs 50,000.

Wrapping up!

Health insurance plays a crucial role in safeguarding individuals and their families from the potentially crippling financial burden of medical expenses. It comes in various types, from individual plans to family floaters, senior citizen coverage, critical illness insurance, and group policies, offering flexibility to cater to diverse needs. However, it's essential to be well-informed about the workings of health insurance, including waiting periods, permanent and temporary exclusions, how to make claims, and more. Renewing your policy and evaluating it periodically is equally important to ensure that it aligns with your current needs and circumstances. 

In a world where unforeseen health issues can have significant financial implications, health insurance stands as a vital pillar of protection, ensuring that you and your loved ones can access quality healthcare without worrying about the financial burden. So, prioritize your health and financial well-being by choosing the right health insurance plan and keeping it up to date.

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