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Health Insurance

The Insurance industry in India has seen lot of changes since the opening of the sector for private participation.

Insurers can now outsource their administrative activities, including settlement of claims, to Third party administrators, who offer such services at a cost.

The job of the TPA's is to maintain databases of policyholders and issue them identity cards with unique identification numbers and handle all the post policy issues including claim settlements.

Leading Health Insurance companies

TPA's in India

Health Insurance also known as Mediclaim in India provides you the cover against the medical care costs arising from disease or accidental injuries.

  • Depending on the terms of the health insurance policy it covers all or part of the medical costs of treating the disease or injury including doctor's consultation charges, medicine and nursing costs. Treatment can be sought in any recognized nursing home or hospital across India.

  • Health insurance in India can be bought both as an individual or a family or as a group.

  • How does health insurance work ?

    To purchase health insurance, you need to pay an annual fee to the company for this coverage known as “premium. You choose the amount of coverage that you want, by paying a high or low premium. The higher the premium the more the coverage. Lets say, you choose a coverage of Rs 500,000 for the year. If during the course of the year,you incur some medical costs due to disease or injury – the insurance company will reimburse you up to the maximum of Rs. 500,000. This Rs. 500,000 can be used in one time or through multiple claims in one year. ”

    This payout by the insurance company can be claimed in two ways :

    1. After the charges have been paid by your upfront. Claimed as a reimbursement.

    2. Cashless settlement – where if the treatment is sought in a hospital which is associated with the insurance provider , the insurance company pays the hospital directly.

    Different Kinds of Health Insurance

    Individual Mediclaim Policy

    This is the plain mediclaim or health insurance policy for an individual protecting this person from the expenses incurred due to disease or injury.

    Floater Policy

    A floater health insurance policy covers your entire family under one policy with one sum insured and one premium. It covers all the expenses as covered under mediclaim only the cover is now extended to the family instead of one person. This cover can be used by any member of the family any number of times. The advantage of this policy is that saves money by spreading the cover across family members.

    Critical Illness Policy

    Insurance companies define certain specified illness or diseases as “critical”. If you have a critical illness policy, then the insurance company will pay you a lump sum payment if you are diagnosed with a critical illness as defined by the insurance company.

    Overseas Mediclaim Policy

    An Overseas Mediclaim Insurance policy provides cover for medical expenses incurred abroad for treatment of illness and diseases contracted or injury sustained during the insured period of overseas travel. Anyone who is traveling abroad for business or pleasure or for educational purposes should have this policy.

    Student Medical Insurance

    Student Medical insurance covers the cost of health care while studying abroad. It is an essential requirement of many foreign universities for its overseas students. Students are generally advised to buy it in India as it is substantially cheaper than buying it abroad.

    Tax Saver

    This is a new class of insurance launched to take full advantage of the income tax benefit under section 80 D of the Income Tax Act 1961. The premium is fixed at Rs 15,000 for all plans. For Senior Citizens aged 65 and above, the premium is Rs. 20,000 This plans includes reimbursement of OPD expenses upto Rs. 10,000. This includes diagnostics tests, dental treatment and related expenses.

    While deciding on your coverage, you may come across a term called “rider”.A rider is a certain add on which gives you additional benefits. You will have to pay for the rider but usually the incremental costs are minimal. You cannot purchase a rider without first having a health insurance policy. Some of the riders commonly available with health insurance policies are :
    a) Accidental Death Benefit

    In case of death of the policy holder due to an accident within the policy period, the nominee (mentioned in the policy) is compensated with the sum that the policyholder was insured for.
    b) Permanent and Total Disability Cover

    This rider insures against the permanent and total loss of limbs or sight due to an accident. This compensation is given as a lump sum benefit. It is payable only if the disablement results in inability of the policy holder to be gainfully employed.

    c) E Opinion Rider

    This rider covers the expenses of second opinion via e-consultation services for a patient based in India suffering from a serious illness. The policy holder can seek a second opinion from a doctor within network hospitals across the world. Qualified physicians from this network must give a written report which includes a diagnosis and treatment plan within 7 working days.

    d) Children's education allowance

    A specific allowance is paid for payment of tuition fees and related costs so that your children's education is not affected during the period that you are indisposed.

    How much does health insurance cost?


    Insurance is usually available from Rs 50,000 to Rs 18,00,000 in multiples of Rs 25000 or Rs 50,000 depending on the insurer. You can choose the coverage that you need depending on your budget and your anticipated needs.

    a) Age of the oldest family member who is proposed to be covered

    The premium is determined by the relative health of the person who is seeking insurance – insurance keeps becoming expensive as you grow older. As older people are considered to be more vulnerable to illness.

    Tax Benefits with Health Insurance?

    As per Section 80D, of the Income Tax Act any amount of health insurance premium paid up to Rs. 15,000. Would be allowed as deduction from the total income for income tax calculation purposes.

    A higher amount of up to Rs 20,000 is permitted for senior citizens.


    Things to watch out for:

    Health insurance will not cover all the costs that you might incur for medical related reasons. But it will still go a long way in saving your money.

    Even after buying health insurance it is essential that you set aside some part of your savings for health related expenses as the product inherently has some limitations that one should be aware of when planning for the future.

    * No coverage for routine medical expenses, checkups or medicines.

    A minimum of a day's hospitalization is needed to claim health insurance. If you incur an expense that does not result in hospitalization (like a hairline fracture for instance), you cannot claim any compensation

    * Limited coverage amount

    Insurance companies usually have a limit of up to Rs 500,000 on their policies. So your compensation is limited to that amount. Modern medical care especially for critical diseases is very expensive and may not be covered by Rs 500,000 alone and you might need to foot the excess bill.

    * Limited coverage for the elderly

    Medical insurance is usually made available only up to a certain age limit (for most insurance companies this is 65 years). So you are above this age limit, you will not be given a fresh policy and on the same lines the existing policy will not be renewed after a certain age. Ironically, this is the age when individuals need financial assistance the most; although the Government and IRDA have encouraged the insurers to take out special policies for senior citizens it is yet to be implemented.

    * Exclusions in policies might result in expenses for you

    Medical insurance policies usually have exclusions. This means that they do not compensate the policy holder for certain illnesses/medical problems. If the policy holder is afflicted by any of these medical problems, he will have to pay for the expenses on his own. Expenditure on pregnancy and related ailments are not covered under individual health insurance policies.

    * Need Protection against loss of income

    Lastly, health insurance only covers the expenses that you might incur for treatment but it does not protect any loss of income due to injury or disease. It should ideally be complemented by disability insurance for total protection of your family.