My family is covered under Ex-serviceman Contributory Health Services (ECHS). She is having health insurance coverage from three other insurance entities. Still continuing. So, there was no pre-existing conditions.

Two and half years back, we have opted for claim re-imbursement only for blood transfusions during the pre-diagnosis period.

Later, her medical condition was diagnosed and the same was falling under IRDA exclusions. She was treated once in-patient and afterwards as outpatient. All claims for admission and medicine re-imbursement were availed from ECHS. (Once I have opted for enhancement of insurance coverage from one insurer and the TPA has refused under these clauses).

Now, after two and half years, she has recovered better (Even Doctor's perception). But she is continuing medicine with lessor dosage. Presently, her condition is fine.

My questions are:

1. Can I avail insurance facilities from insurance companies for the same issue in future? 
2. Can I avail insurance facilities from the insurance companies, for other issues than the specifically excluded?
3. Can I prefer ECHS for any eventualities for the specified issue to the extent admitted, and remaining expenditure from other insurance companies?

Please guide.

Ans: Hi Mr. Tripathi, greetings to you. To answer your first question as to why Aditya Birla won’t provide you with cashless claim as opposed to TATA AIG is because the policy you bought from Aditya Birla is a ‘Super top up plan’ which basically means it is an addition to your base policy which in your case is your TATA AIG policy.

Super top up policies do not offer cashless claims but only provide reimbursements.

The one lakh gap, unfortunately, cannot be filled at this point. However, while renewing your policy you can opt for increased sum insured with TATA AIG. The insurer will ask you a set of questions and schedule medicals to analyse your risk profile. Post that based on your reports, the insurer will take a decision on increasing the limit.   

Ans: Hi Thangavelu, good to know that your wife is doing well. To answer your first query, yes you can declare your critical illness and avail the rider for it. Another option is to purchase a new plan for critical illness from an insurer of your choice. The insurer will ask a set of questions and based on that the coverage will be provided. However, most of the insurers will keep the PED in the Permanent exclusion list. As far as your query on continuation of policy is considered, you can continue with the existing health policies you have.

Any medical condition which arises after the waiting period of the policy will be covered in the health policies. Which is why check for the waiting periods associated with different ailments in your policy document.

Ans: The clause is termed as ‘Moratorium Period’ and according to this after the completion of 8 continuous years no health insurance claim shall be contestable for non-disclosure of relevant information at the time of policy issuance except for proven fraud and permanent exclusions specified in the policy contract.

Ans: I truly appreciate your clarity. Let us assess it carefully.

Assessment of Your Current Coverage
You both have ECHS coverage. ECHS is a comprehensive scheme for ex-servicemen.

It covers major illnesses and many critical treatments at empanelled hospitals.

The facilities are usually cashless in these hospitals.

It is great that you have this cover. It reduces financial pressure for most treatments.

But it does not cover all possible scenarios fully.

Sometimes certain new therapies or expensive drugs are not covered.

Also, ECHS coverage may have some limits or long waiting periods for some treatments.

Some private hospitals may not be fully under the scheme.

Need for Additional Critical Illness Cover
At 57, critical illness insurance can be expensive.

You rightly said it seems unaffordable now.

Generally, premiums rise sharply with age.

A critical illness cover pays a lump sum if diagnosed with serious illness.

But given your age and high premiums, the cost-benefit is not favourable.

It is also often limited to a certain number of illnesses.

Since you have ECHS, you have a strong base cover for treatments.

This includes treatments for cancer, heart issues, etc.

So, ECHS takes care of most critical illnesses from a hospitalisation view.

Recommendations
Given your retirement and limited affordability, skip buying new critical illness cover.

It is better to strengthen your savings and keep a health emergency fund instead.

Set aside some money in safe options like liquid mutual funds or FD.

This can be used for non-hospital expenses if a critical illness occurs.

Expenses like home care, special diet, travel, and other non-medical costs can be met from this fund.

Review your ECHS benefits booklet in detail.

Check what illnesses and treatments are covered and where.

If needed, visit an ECHS polyclinic and clarify your doubts with them.

Also, maintain good health practices.

Eat a balanced diet, exercise moderately, and take regular check-ups.

Managing stress and staying active helps reduce health risks.

Exploring Alternatives to Critical Illness Insurance
Instead of insurance, focus on boosting your emergency health corpus.

Keep at least 6-12 months of expenses in an easily accessible account.

This should be separate from your usual savings.

Avoid putting large sums in long-term products now.

Keep funds accessible for any sudden need.

In case of any serious illness, your first line of defence is ECHS.

If there is any shortfall, your emergency corpus will help.

Additional Points for Financial Security
If you have any investments in mutual funds or stocks, review them carefully.

At this stage, avoid risky investments like small caps or thematic funds.

Shift more to conservative or balanced options.

Do not take loans or withdrawals from your retirement corpus.

Keep your expenses in check and avoid high-luxury spends now.

If your children are financially settled, avoid gifting large amounts.

Focus on your own and your wife’s comfort and security.

If you have any life insurance policies (LIC or others), review if premiums are needed.

Sometimes, old policies may no longer be useful if there is no financial dependent.

Also, check your will or estate planning documents.

Make sure they are up to date and your wife knows about them.

Benefits of Not Taking Critical Illness Cover Now
Premiums at your age are very high.

ECHS already covers hospital costs for most serious illnesses.

So, you save on insurance premium money.

You can use that money to build a medical emergency corpus.

No need to worry about claim denials for pre-existing conditions.

Less paperwork and no extra policy to manage.

You also avoid the disappointment of policies that do not pay for newer treatments.

Instead, you can use your emergency corpus flexibly.

Best Way Forward
Do not buy additional critical illness insurance.

Focus on building a liquid medical emergency corpus.

Use your ECHS as the primary cover.

Maintain good health and keep your expenses under control.

Review all existing investments and make them more secure.

Keep 1-2 family members informed about your ECHS and other investments.

This ensures no confusion in emergencies.

If you feel unsure, consult a Certified Financial Planner.

They will guide you in balancing investments, health costs, and retirement income.

Finally
ECHS gives you a strong base of health coverage.

At this stage, a critical illness policy is too costly and not needed.

Focus on an emergency corpus, healthy habits, and careful investing.

You have done well by thinking ahead.

With these steps, you can enjoy your retirement with confidence.

Best Regards,

K. Ramalingam, MBA, CFP,

Chief Financial Planner,

www.holisticinvestment.in
https://www.youtube.com/@HolisticInvestment