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Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on May 31, 2022

Sanjib Jha is the CEO of Coverfox Insurance. His expertise includes health and auto insurance. He has over 22 years of experience in the financial sector. He has completed his post-graduation from the Institute of Company Secretaries of India.... more
Bhupesh Question by Bhupesh on May 31, 2022Hindi
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This is Bobby here and have a few questions related to your article (enclosed), Mediclaim: What You Must Know

Would like to know, with your experience in this field, as to:

1. Which mediclaim policy or policies, currently in INDIA and especially Mumbai has all the required coverage as mentioned in your article

2. We are a family of 3 with a school going child and both of us are aged 45

3. Have acquired diabetes a few months ago and have hepatitis B and kidney stones 

4. What should be the approximate premium, per annum to cover all that is mentioned in your article and keep us safe from the issues arising out if and when we really require hospitalisation and save us from rejected claims.
 
5. Presently we are covered under Mediclaim policy from Star Health

Would be highly obliged should you guide us on the above to make our lives easier.

Ans: Hi Bhupesh, there is no ‘one size fits all’ concept with health insurance. Health insurance is based on preferences of the customer and then the premium quotes are generated based on those factors. You can use insurance broking websites to compare the offerings on the mentioned 5 factors and the premiums for various policies that will help you to compare their benefits and make an informed choice. Depending on your priorities, weigh out the factors and decide accordingly.

Since you have mentioned about your family, you can opt for Family Health Insurance policies with an appropriate sum insured to cover your entire family. Like I have mentioned before, premiums are unique to individuals depending on their preferences, the sum insured they deem suitable, the riders they choose, their medical history etc.

What you can do to ensure you buy the correct policy for yourself is to evaluate policies carefully, keeping in mind the 5 important parameters.

:
DISCLAIMER: The content of this post by the expert is the personal view of the rediffGURU. Users are advised to pursue the information provided by the rediffGURU only as a source of information to be as a point of reference and to rely on their own judgement when making a decision.
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Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on May 31, 2022

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I read your today's article about Mediclaim: What You Must Know. Thank you for some important information and points shared. I have some questions about the Mediclaim policy. I have been buying a Mediclaim policy since 2007 and I have not claimed it till last month. Last week I was hospitalized for gall bladder stone surgery. When I asked the hospital to use the cashless option on my Mediclaim policy for claims they gave an estimated cost of about 1 lakh. And same if I claim myself, they gave an estimated cost near about 55 thousand.  1. Why and what is the difference between these charges? How did the TPA approve cashless? Is there any guideline or standard process for hospitals that can claim more charges in cashless options? 2. Why do cashless charge more? Due to this type of charges for cashless claims the sum insured amount decreases after treatment. We can utilise the same difference charges amount for another treatment.
Ans: Hi Vilas, in order to understand the difference in the estimated costs, you should ask the hospital on what parameters they have estimated the two costs. Questions on treatment protocol, room charges and type, doctor’s fee etc., should be asked.

When choosing cashless treatment, the patients often opt for the best facilities that they may not have opted for otherwise. Sometimes hospitals may run some additional tests as well in order to avoid back and forth on your claim settlements, when it is a direct transaction between insurer and the hospital.

However, if you feel that you are being overcharged, then you should report any discrepancy in what you are being charged for, to the insurer. Insurance companies take such cases very seriously, which is why insurers have preferred network hospitals that agree on a certain pricing for various treatments and other tariffs.

In case it is observed that there is any abuse of cost or sum insured then there is a chance of being de-paneled and hence a check is in place.

..Read more

Sanjib

Sanjib Jha  | Answer  |Ask -

Insurance Expert - Answered on Jul 28, 2022

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My Oriental Mediclaim coverage is for Rs 5 lakh under Royal Mediclaim cashless scheme vide PNB. I have completed 36 months, a conditional requirement (a facility only for PNB customer). In this regard I have a few questions...
Ans: Hi Anoop, thanks for sharing your queries, will take them one by one.

1. What's the meaning of 5 lakh coverage? Will I get a full 4.95 lakh for both knees transplant (my hospital package is costing 4.95 lakh from entry to exit)?

Sanjib Jha:  A coverage of 5 Lakh means your policy covers you up to 5 lakh and you can claim it. However, the coverage amount for knee transplant depends on insurer to insurer as few of the policies having certain capping on the coverage amount for such treatments.

2. When the hospital sent the proposal to TPA, only 2.47 lakh were provisional sanction. What's the meaning of provisional? I was told that the final amount will be settled once final bill is produced by the hospital. Does it mean that 4.9-2.47=2.43 lakh or so, will be settled and remitted to the hospital by Oriental insurance? 

Provisional Sanction amount is the amount that the insurer approves based on the ailment i.e., knee transplant in your case. The rest of the amount approval is provided based on the final bill generated by the hospital.

3. When I sought clarification from TPA, I was verbally told that now the final amount cannot be decided. Only after the final bill it can be. Nothing said on email. No replies from Oriental insurance of my email query.

For policies issued by Oriental, the claims are handled by TPA (Third Party Administrator). I advise you to raise the concerns to TPA via email or via TPA desk to get the clarification. Also, the insurer can provide the final approval after the final bill is generated by the insurer, deducting the non-approved cost as per policy terms & condition.

4. Hospital insists that I deposit 50% (2.5 lakh) cash from pocket before admission.

As it seems that the insurer has provided pre-approval for 2.47 lakh, the rest amount you will have pay to the hospital & the same will get approved by the insurer once the final bill is generated by the hospital.

5. If I have to pay cash, then where is the cashless scheme?

I advise you to check the terms of your policy. Often certain treatments are not covered in particular policies, which is why it is extremely important to read your policy document thoroughly and ask all your queries to the agent/Insurer before purchase. For specific ailments, there are add-ons offered by insurers and accordingly one should opt for those add-ons.

..Read more

Ramalingam

Ramalingam Kalirajan  |6592 Answers  |Ask -

Mutual Funds, Financial Planning Expert - Answered on Jul 11, 2024

Asked by Anonymous - Jun 24, 2024Hindi
Money
Hello sir, my age is 40 yrs currently unmarried. Recently, I had to undergo a renal transplant surgery since I was suffering from AKD (Acute Kidney Disorder) in Bangalore. I was on dialysis for last one and half yrs and moved to bangalore just for the surgery. It went well and now I am on the road to recovery.We had a health insurance policy by manipal cigna company (medi-assist) which ensured that every expenses was met through reimbursement like dialysis expenses, OPD chgs, pharmacy bills etc. We were satisfied with the services of the health insurance provider. My question here is that can I take any more health insurance policy now (may be from a different company) for my future medical expenses which might occur in future (considering I am pretty young right now and single too). What premium do I need to pay for that? Will it be increased premium or the same normal premium. I might not use the health cover for my renal disease now but as a safeguard for the future diseases which may come up.(considering I will get married and have a family too in future). Will my kidney surgery have any impact on the future health cover or not? Kindly advise.
Ans: I'm glad to hear your surgery went well, and you're on the road to recovery. Considering your situation, it’s important to secure your health insurance needs for the future. Let’s break down your questions and concerns regarding taking an additional health insurance policy.

Can You Take Another Health Insurance Policy?
Yes, you can take another health insurance policy from a different company. However, your recent medical history, including the renal transplant surgery, will impact your new policy's terms and premiums.

Impact of Renal Transplant on New Policy
Pre-Existing Conditions: Your kidney surgery will be considered a pre-existing condition. Most insurers have a waiting period for covering pre-existing conditions, ranging from two to four years. It’s crucial to check the specifics with any new insurer.

Medical Underwriting: Given your recent medical history, the insurer may require detailed medical underwriting. They may request your medical records and possibly a medical examination to assess your current health status.

Premium Considerations
Increased Premiums: Due to your pre-existing condition, new health insurance policies are likely to come with increased premiums. The exact amount will depend on the insurer's assessment of your health risk.

Loading Charges: Some insurers might add a loading charge to your premium, which is an additional cost to cover the higher risk associated with your medical history.

Types of Policies to Consider
Individual Health Plans: These provide coverage for a single person. Given your situation, ensure the plan offers extensive coverage, including post-operative care and critical illness coverage.

Family Floater Plans: These plans cover multiple family members under a single sum insured. They might be a good option if you plan to get married and start a family in the near future.

Critical Illness Plans: These plans provide a lump sum amount upon diagnosis of specified critical illnesses, including kidney-related issues. It can be a supplementary policy to your primary health insurance.

Steps to Take
Research and Compare: Compare policies from different insurers. Look for policies with comprehensive coverage and a reasonable waiting period for pre-existing conditions.

Consult Insurers: Speak directly with insurance representatives. Explain your medical history and get clear information on how it will affect your premiums and coverage.

Read Policy Documents: Carefully read the policy documents, especially the sections on pre-existing conditions, waiting periods, exclusions, and premium loading.

Consider Riders: Look for riders or add-ons that can enhance your coverage, such as critical illness riders, hospital cash, and personal accident covers.

Consulting a Certified Financial Planner
Given the complexities of your medical history and future health needs, consulting with a Certified Financial Planner (CFP) can be very beneficial. A CFP can help you understand the nuances of different policies, assess your long-term financial needs, and recommend the best health insurance options tailored to your situation.


You’ve shown great foresight in considering additional health insurance despite your recent surgery. Ensuring your future medical needs are covered demonstrates a strong commitment to your long-term well-being. Your proactive approach to securing your health is commendable and shows a responsible attitude towards managing potential future risks.

Final Insights
Securing an additional health insurance policy is a wise move, especially considering your recent medical history and future plans. While premiums might be higher due to your pre-existing condition, thorough research and consulting with professionals can help you find the best policy for your needs. Remember to compare different plans, understand the terms, and choose a policy that offers comprehensive coverage and aligns with your financial goals.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in

..Read more

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