In the first part of the story, we started off by comparing premiums, etc. Now, let's continue further.
Look at the fine print
Insurance is one financial product that has a history of surprising its buyers right at the time when they need it the most. Do not ever buy a health-insurance plan without going through the fine print. Of course, going through each and every word of the lengthy terms and conditions can be pretty gruelling but you must check and confirm the following crucial points. Visit the insurer's website and you will find the policy wording in the 'Downloads' section. If not, ask the insurer's customer-care team to help you with the written document. Don't settle for verbal information. Once you get the document, which is usually in the PDF format, look for the following keywords (written in blue). Thanks to technology! Just pressing two buttons (Ctrl+F) can save a lot of time.
Sub-limits: Some of the most common sub-limits that are often present are a cap on the room rent, ICU charges and doctor's fees. For example, an insurance plan with this clause normally limits the room rent to 1 per cent and the ICU charges to 2 per cent of the total sum insured. So, if someone has a health-insurance cover of Rs 5 lakh, with such a clause, the insurer will not provide for the room rent and ICU charges beyond Rs 5,000 and Rs 10,000 per day. Having a reasonable sub-limit on certain procedures like cataract surgery is fine but having the limitation even on the smallest of the things, like the room rent, can be quite discomforting during the need of the hour. It is, therefore, better to have a plan that does not have any such sub-limits. Remember, government insurers and a plan with a cover of less than Rs 10 lakh by a private insurer are more likely to have this clause. Obviously, the lesser the sub-limit, the better it is.
Co-pay: This usually mandates the insured to meet a certain portion of the treatment costs out of his pocket. For example, if there is a co-pay clause of 10 per cent and the hospital bill amounts to Rs 5 lakh, then the insurer will only provide a benefit of Rs 4.5 lakh at the maximum. The insured will have to pay Rs 50,000 from his own pocket. This clause is very common if the age of the insured is 60 or more. So, do check this if you have the elderly at home for whom you are planning to buy the health cover. Ideally, the lower the co-pay percentage, the better it is.
Exclusions: All insurance companies have certain exclusions - the diseases that they do not cover. These exclusions can be permanent or temporary. Temporary exclusions are applicable only for a certain period after buying the policy and those exclusions are removed after continuing the policy for a certain period.
On the other hand, dental treatment, cosmetic surgeries and the treatment of HIV fall under permanent exclusions of almost all health-insurance policies. Pre-existing diseases are usually covered after two to four years of buying the policy. This is usually referred to as the waiting period and varies for each insurer. It is common to have certain lifestyle diseases like diabetes and hypertension these days. If you have any, look for the shortest waiting period. Besides pre-existing diseases, an insurance policy may not provide a cover for certain medical conditions, such as cataracts and hernia, in the initial years.
Domiciliary hospitalisation or treatment at home: The benefit of this clause kicks in when the hospitalisation is required but can't be done because of the unavailability of hospital beds or for the reason that the insured is severely ill/injured and cannot be moved to the hospital. Given the shortage of hospital beds during the second wave of the pandemic, this clause has become more important than ever. It is even more important if you have the elderly at home. However, most insurance plans have a sub-limit here and provide the coverage only when the treatment lasts for a certain period, usually three days. Having the facility of home treatment in your policy adds value, provided it does not cost you too much in terms of a high additional premium.
Restoration benefit: This feature refreshes your sum insured as soon as it gets exhausted during a year. Insurance companies can play quite a bit here. Some companies can provide restoration without any limit on the number of times it can be done, while others limit it to just one time. Further, some companies do not allow the insured to use the restoration benefit for the same illness for which he/ she has already been hospitalised in the same year. But some policies do not have any such limitations. Restoration seems to be an attractive feature to buyers but it may well turn out to be an expensive marketing bait. So, don't go overboard on getting the highest number of restorations, as it will likely result in a jump in the premium amount. This is where you need to explore a bit. For example, if insurer X provides you with a Rs 10 lakh cover with one-time restoration at a somewhat similar premium as insurer Y who is offering Rs 20 lakh cover with no restoration, isn't the latter a better deal, all else being equal?
Annual medical tests: Some policies have now started providing for the annual health check-up. This can be a useful feature to look at, though not mandatory. But you must inquire about the centres from where you can get these tests done, what sort of medical tests are covered and whether the cashless mechanism works there.
Pre- and post-hospitalisation: While most policies do provide cover for pre- and post-hospitalisation treatment expenses, the coverage may vary on the number of days. One should look for a prehospitalisation cover of at least 30 days and a posthospitalisation cover of 30-60 days, which should be sufficient in most cases.
This is the second part of the story. You can read the last part here.