4. What are the most common exclusions in a health plan?

Ans:

Health insurance is a safety net for the financial well-being of an individual or a family. With medical inflation close to 15 per cent year on year, it has become imperative to opt for a comprehensive health insurance plan for the entire family so that the hospitalisation expenses are taken care of.

A comprehensive health insurance plan is an indemnity plan and hence pays for all expenses incurred during hospitalisation. It typically covers all hospitalisation expenses related to an illness, injury or an accident.

So, from the time of hospitalisation, the cost of an ambulance, room rent, medicines, diagnostic tests, surgery/ implant or any other treatment procedures, etc. would be covered under in-patient hospitalisation. Additionally, pre- and post-hospitalisation expenses for diagnosis and follow up treatments, AYUSH treatment, domiciliary, organ donation, etc. treatments and procedures are usually included.

There are other value-added benefits of comprehensive health insurance plans as well; such as free annual medical check-ups, sum insured restoration benefits, maternity and other covers. You can further enhance the base coverage by purchasing optional add-ons like personal accident and critical illness coverage.

Ans:

Yes. If you have any major health ailments in India -- whether it's Thyroid, BP or Diabetes -- you can still avail of your hospital and medical expenses. There are policies available for patients with the common complications of prevalent conditions like diabetes and thyroid. There is health insurance coverage accessible for everyone, but make sure you notify your insurance provider of any illnesses and understand your policy's coverage.

Thus, when you fill up your proposal form for a health insurance plan, you need to disclose all material facts; else your claim might be rejected on the basis of non-disclosure or misrepresentation of material facts. So, if you have high blood pressure or diabetes, just remember to mention it along with the list of medications prescribed to you. Then, the underwriter will assess your risk and quote the premium accordingly. Also, there could be a waiting period, or, an exclusion attached.

Once the health insurance plan is accepted with the specified risks, all expenses associated with your pre-existing ailment would be covered by your insurer.

Ans: The difference between these two policies is that in a family floater more than one family member is covered under one Sum Insured whereas an individual policy covers only the named individual. Also, in case of family floater policy, the premium paid is generally lower than cumulative individual policies.

Family floater gives higher discount as several family members share the defined sum insured. Hence it can be a smart option for your financial health. However, in case of a family which has aged or elderly members, a family floater may not be appropriate as the premium in case of a family floater is highly dependent on the age of the eldest member.

Also, the sum insured may not be adequate for the family in case of a more complicated health intervention. A floater works best for a younger family.

Ans: Top-up policies play the role of an emergency backup policy, when their main health insurance policy cover reaches the threshold of the sum insured. It offers a higher coverage at relatively lesser premium as compared to a base policy with a higher sum insured.

Ever increasing medical inflation and ongoing deadly infection makes it essential to not only have health insurance but also insurance cover with an adequate sum insured.

The need of a specified sum insured can be optimised by breaking it into two policies. One basic and another top up totalling up to sum insured required by you. This option is recommended rather than having a single policy with higher sum insured.

Ans: Determining the ideal coverage amount for health insurance depends on various factors, including your financial situation, lifestyle, and specific needs. Here are some general guidelines:

• Medical Costs: Consider the potential medical expenses you might incur, including hospitalisation, surgeries, and treatments. The coverage amount should be sufficient to cover these costs.

• Family Size: If you are purchasing a family health insurance plan, ensure that the coverage amount is adequate for all family members.

• Preventive Care: Look for policies that cover preventive care, vaccinations, and health check-ups.

• Network Hospitals: Consider the availability and quality of network hospitals covered by the insurance policy.

• Deductibles and Co-payments: Be aware of any deductibles and co-payments that may apply and assess how they impact your out-of-pocket expenses.

• Renewal Age: Opt for policies with a higher renewal age to ensure coverage into your senior years.

Exclusions:
Insurance policies typically have exclusions, which are specific situations or conditions not covered by the policy. While the exclusions can vary between insurers and policies, here are some common exclusions you must know:

• Pre-existing Conditions: Many health insurance policies have a waiting period for pre-existing conditions. Treatment for these conditions may not be covered during the waiting period.

• Specific Treatments: Some policies may exclude coverage for certain treatments or procedures, such as cosmetic surgery or alternative therapies.

• Hazardous Activities: Life insurance policies may exclude coverage for deaths resulting from hazardous activities, like extreme sports or certain occupations.

• Suicide Clause: Life insurance policies often have a suicide clause, typically excluding coverage for suicides within the first two years of the policy.

• Misrepresentation: If you provide inaccurate information during the application process, it could lead to policy cancellation or denial of claims.

• War or Acts of Terrorism: Some policies may exclude coverage for deaths or injuries resulting from war or acts of terrorism.

It's crucial to carefully read the policy documents, including the terms and conditions, to understand the specific exclusions that apply to your insurance coverage. If you have any doubts or concerns, consider consulting with an insurance professional or agent for clarification.