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The Inhouse Gyan Guru, Blog Writer, Life Enthusiast


Body is a machine. How well you maintain it, will decide how long it does lasts, without a break down.

This brings us to the ever known fact that every human being has to take care of their body, in order to remain self dependent and live life to the fullest.

But in case they do need medical care and advice, they should have a health insurance in place, unless they have a backup plan.

What is health insurance –

Health insurance cover means a contract between the insurer and the insured, wherein the insurer promises to cover the insured for defined medical expenses they might incur in return for a fixed amount of premium.

Always remember – Don’t go for the lowest hanging fruit when it comes to health cover

In terms of health policy, refrain from going for the cheapest cover as it can have caveats attached to it. (We will discuss the same in detail in this article). Go for the most economical plan according to your own health needs.

You need to evaluate the following aspects before deciding on a health policy.

You and your family’s –

  1. Health history
  2. Life style
  3. Future earnings and
  4. Future Health expenses including premiums and out of pocket

Listed are few of the specific aspects you have to look for before deciding on your health insurance. As the cost of insurance is not just the premium but the total out of pocket expenses you pay to avail the facility.

1. Co pay

a. It means that when any health claim arises, the insured will have to pay part of the expenses (defined in % or amount) and the rest will be paid by the insurance company. Eg if you are going for a surgery costing Rs.40000 and the said treatment is under co – pay of 90- 10%, then the insurance company pays Rs.36000 and you will have to pay the balance Rs.4000.

b. Reasons for such clauses –

  1. This ensures that people go for treatments only when required and not for any small ailment which can be treated at locally.
  2. Treatments are taken at reasonable hospitals and not boutique ones with inflated costs.

Benefit for customers – they get larger sum assured at lesser premium as they agree to bear part of the expenses.

2. Deductible

a. The minimum expense amount beyond which the insured can claim insurance. Suppose if your policy has a Rs.2000 deductible clause and you incur a health expense of Rs.2000 or less, then in such case no claim will be paid. If you undergo a cataract surgery cost Rs. 30000 then the insurance company will pay Rs. 28000 as a claim and Rs.2000 is borne by the insured.

b. This clause is inserted as a fixed amount so that the insured refrains from filing small amount claims thus refraining from wasting the time and effort of both the insurer and the client.

3. Sub Limits

Ailments based sublimit –

An insurance policy sum assured is a combine cover provided for all possible ailments. Hence, there is a maximum claim limit called sub limit for each of these ailments within the sum assured. eg if the Sum assured is Rs.10 Lacs, and there is a sublimit of Rs.25000 for kidney stone operation, any cost above the sublimit of rs.25000 will have to be borne by the insured.

Room Rent sublimit –

Room rents are always included in sublimit, unless you take an all inclusive policy with no sub limit. And all hospital expenses right from operation theatre cost to doctor costs, food and other expenses are all linked with room rents.

Eg if your policy allows a room rent of Rs.2000 per day and you go for a room costing Rs.5000, you not only have to pay the difference in room rates ( 5000-2000 =3000) , you will also get only proportionate claim from insurance company for all expenses incurred. So if your total hospital expense is Rs.70000 you will get a claim of Rs.28000 (2/5 x70000), even though you’re eligible sum assured is more than RS.70000.

This is because all hospitals calculate their charges, for same service provided, according to room rents. That means a treatment availed in a twin sharing room will cost less, for same procedure, as compared to a single room.

4. Pre existing condition

A pre-existing condition means any health ailment faced by the insured before applying for insurance. These can range from big issues like diabetes, cancer, PCOS, asthma to even simple aspects like acne. Usually different insurance companies have different waiting or cooling periods for these listed ailments, before they cover them. These range from 2 years to 4 years. Hence based on your requirement, you should shop and choose the insurance company product.

Now comes the moot point .. what should a layman do when it comes to deciding on a health plan.

Following are the recommended options-

1. Basic health plan – with co pay, deductibles and sublimit.

Go for it if …

If you don’t expect to use the medical services regularly, you can take a high co pay and deductible. This ensures a low premium out flow.

If you have an employer provided health policy and just want to have a add on cover to take care of any spill over.

If you are constrained by budget but want a large sum assured and also intend to chip into your health costs in near future

2. Medium coverage plan –

Go for it if …

If you want cost savings in terms of out of pocket then you go for a health plan with small co pay and deductibles.

3.Comprehensive plan – top end plan

Go for it if …

If you know, there are fair chances of you or your family member going for regular doctor visits and medical requirements, then go for the comprehensive plan.

In case you have good amount of funds, then go for a health policy which ensure you have no co pay, deductibles, sub limits and less waiting for pre existing diseases.

It is called Comprehensive Health Policy.
This plan involves high premiums but then takes care of your complete medical expenses within the prescribed policy rules. There is no sub limit, co pay or deductibles and it provides high Sum Assured.

End of the day … Well planned out investments … lots to look forward to in your defined budget.

And …. do take care of your body .. It’s the only place you have to live …

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