Checklist of critical issues about selection of a medical insurance policy

This is in continuation with an earlier blog on the medical insurance currently being offered by many companies for the elderly in India. Here is a summary of the more critical elements of the policy on offer that one (especially a senior citizen) should be watching out for and be careful about.

• Sum insured (range and the maximum amount)
• The annual premium for individual/family floater scheme as the case may be
• Maximum entry age
• Maximum renewal age (For some policies the renewal is said to be guaranteed life long. However, the relevant policy wording usually allows for the insurer to put the insured under “the then prevailing health insurance product or its nearest substitute” as approved by the insurance regulatory authority, IRDA. This may effectively mean enhancement of the premium or other conditionalities not present in the original policy)
• Is there a loading of the renewal premium depending on the claims
• Percentage co-pay for the age-band concerned and that for treatments in a non-network hospital (make sure the hospitals of interest in a given location are included in the list of network hospitals)
• Sub-limits on various components of medical expenditure incurred as an in-patient (accommodation, especially the type of accommodation, nursing, medicines/drugs, diagnostic tests of all kinds, OT charges including equipment, consumables, medicines, anaesthesia gases, blood, oxygen, prosthetics (if implanted inside or fitted externally on the body, fees for surgeons, anaesthesists, additional specialists (if required for the procedure), technicians and attendants)
• Sub-limits/package rates applicable to specific surgical or other procedures and special diagnostic tests
• Check the definition of ‘one illness” and the number of days (usually about 45 days or so) before which a repeat hospitalisation  for the same disease or a relapse may mean that this will have to be part of the ‘one illness’ and therefore one claim (this may adversely affect in case of sub-limits such as above)
• Pre- and post-hospitalisation benefits (check the sub-limits and other conditionalities)
• Check the list of day care procedures (Usually these are allowed only as in-patients and not taken in the hospital OPD. Advisable to check with the insurer if they will make an exception if either the hospital concerned does not agree to such an admission due to non availability or other reasons and offer to carry out the procedure at the OPD instead)
• Mandatory waiting period (30 days/90 days) for the first proposal
• Special waiting periods (usually two years) – check the list of diseases for which these waiting periods are applied (in this way treatment of many common diseases and surgeries that may be of interest to everybody, especially senior citizens, are expressly disallowed for as long as 24 months, while one keeps paying the premium)
• Waiting periods related to the pre-existing diseases (usually four years) – check carefully what the insurer defines as a pre-existing disease
• Policy about the waiting periods in the event of the portability from an existing policy with another company
• Claim settlement process – whether in-house or through a TPA
• Response time in the case of cashless hospitalization procedure – both for pre-authorisation and during discharge