Buying mediclaim? 7 important things you must know

Drop us a line and our expert, Harsh Roongta, CEO of Apnapaisa.com, will answer it.

Please write to us at getahead@rediff.co.in with the subject line as: Health insurance query.

I am 52 years and am diabetic for the last 18 months. Can I get a mediclaim policy?

Firstly whichever policy you take make sure you fully disclose your diabetic status so that you do not face a problem in making claims in the future. You can go ahead to take any policy but diabetes will be covered after specified number of years (ranging from 3 to 5 years) in the policy. New India offers a special plan for diabetic patients where you can cover your disease on payment of extra premium from the second year onwards.

I am 80+ and my wife is 73. We stay alone and are in reasonably good health and never been hospitalised. Can we get insurance cover for hospitalisation or disabling injury in our balance years?

Getting a health insurance for yourself at this age would be a tough deal but you can certainly cover your wife. Max Bupa would be the only insurance company, which can give you insurance above the age of 80. Disability insurance at this age is highly tough as no company offers disability insurance at an age of above 80. For you wife, you can go for senior citizen plans offered by National Insurance or United India Insurance. You can also opt for Star Health -- Medi Classic.

Please note that your wife would have to undergo various medical tests at your own expense and policy will be issued based on these reports.

My age is 29 and I would like to take health insurance policy for around Rs 3 lakh and I have a basic doubt regarding the tenure of the policy. What is meant by number of years in the policy? Can a person have the insurance for the complete life if I am willing to pay the annual premium? If yes, please suggest a good plan for the same.

Health insurance plans are generally one-year plans. Some companies offer the plan for 2 years, but no company offers a plan for the entire life. You will have to renew the plan every year. However, each company is required to indicate up to what age the policy will be renewable by them. Some companies such as Apollo Munich, United India, Oriental Insurance and Max Bupa allow renewability up to lifetime on some of their policies.

The Insurance companies cannot deny renewability except on the grounds of fraud. So effectively you get a long-term cover provided you pay premiums and renew your policies on time.

If I am willing to take an insurance policy for 10-15 years at least, then will the insurance company have the fixed annual premium or will they increase the premium based on the age and diseases encountered in the future.

All health plans provide for an increase in premiums based on the age of the insured person. Some plans provide for increasing the premium from the subsequent years if a claim is made in a previous year. The percentage of such increase (also known as Loading) is pre-specified in the policy document. Also premiums can be increased with the prior approval of the industry regulator the Insurance Regulatory Development Authority. Some companies such as Apollo Munich, United India, Oriental Insurance and Max Bupa allow renewability up to lifetime on some of their policies. The Insurance companies cannot deny renewability except on the grounds of fraud. So effectively you get a long-term cover provided you pay premiums and renew your policies on time.

I work at Sasken Communications limited. Recently I had to undergo treatment for Dorsalgia and I had applied for medical reimbursement but after some days I was told that my claim has been denied. I had told them the reason but still nothing I have received. Could you please suggest me what could I do?

It is not clear if you were hospitalised or not for the treatment of chronic back pain (Dorsalgia). If you were indeed hospitalised for treating this disease/illness then there should be not be a problem in getting reimbursement of the hospitalisation expenses within the policy limits. Please log in a complain with the concerned insurance company on their website. If you don't get a reply from them within a period of 3 to 4 weeks, you can put in your complaint with the insurance ombudsman who will look in to the same.

Please let me know on what basis pre-existing disease is considered.  Is it a disease at the time of taking the policy or a disease that occurs during the policy period?

Pre-existing disease is when you take the policy for the first time. Any disease you are suffering at the time of buying the policy comes under the clause of pre-existing disease.

Can I take two insurance covers and mediclaims from two different companies, that is, New India and United India? Kindly let me know if it is advisable or not?

You can take insurance policies from two insurance companies. At the time of claim you can claim from both the insurance companies who will pay you the claim on a pro rata basis of the sum insured of the policies. It is administratively inconvenient and it would be better for you to take a larger policy from any one company you prefer.

I am 40 years old. I am with my wife and two children aged 10 & 6. I have a mediclaim of Rs 75K for Rs and 25K each for my family member, all from Oriental Assurance Company. I have been detected with cancer in January 2010. My expenses shall rise now. Is there any policy which covers the existing critical illness and if any please suggest a few so that I can increase my limits now.

Unfortunately, there is no policy, which will cover you for your pre-existing disease. You may certainly choose to increase the sum assured of your family members to protect them from any kinds of disease in future Since they are grossly under insured.

I wish to buy a mediclaim policy for my family: My father (57), my mother (57), myself (31), my wife (30) & my child (2). My father is suffering from diabetes & is on Insulin for last many years. My mother is having the problem of high BP. I wish to ask:
 
1) Is there any policy where my parents can be covered?
2) Is there any family floater policy, where all 5 of us can be covered in a single policy?
3) Are private insurers better than government ones regarding the claim settlement process?

It is advisable to take individual policies for your parents rather than a family floater policy. Firstly whichever policy you take make sure you fully disclose your diabetic status so that you do not face a problem in making claims in the future. You can go ahead to take any policy but diabetes will be covered after specified number of years (ranging from 3 to 5 years) in the policy. New India offers a special plan for diabetic patients where you can cover your disease on payment of extra premium from the second year onwards.

Unlike life insurance, no objective data is available regarding claims accepted and rejected or partially accepted by various health insurance companies. Similarly it is not possible to provide any objective criteria for service standards of an insurance company. In term of criteria the following are the things you should look at:

1. Staying with the same insurance company is very important since once you are hospitalised with a disease it will continue to be covered in later years only if you buy the policy from the same insurer. If you shift to another insurance company at that stage that particular disease will be treated as a pre-existing disease by that company and will not be covered for a few years.

2. Policy renewable up to: It is a known fact that it becomes difficult to get a fresh policy as your age increases just when your need is the highest. Hence the maximum age up to which the policy is renewable, is very important.

3. Premium increases in later years. Insurance companies have different pricing startegies and depending on your age the premium is different. So it is advisable to look at not just current premiums but also future premiums.

4. Permanent and temporary exclusions: Most policies exclude hospitalisation expenses temporarily or permanently for a whole lot of diseases or treatments. This is different for different companies. You should look at the policy workings to get a sense of what is permanently or temporarily excluded.

5. Co-pay and sub-limits: Some companies have sub-limits for different heads (say doctors fees is limited to 25 per cent of the sum assured) which can have an impact of your claim. Some companies require you to partially meet the cost of every treatment (co-pay). Both restrict your claim amount and hence should have an impact on your decision.

6. Coverage of pre-existing disease: Different companies cover pre-existing disease in separate ways. Some will cover it after 2, 3, 4 or 5 years. Also, some put in an additional condition that during these 2, 3, 4, or 5 years there should have been no claim on the policy. Some others also put in a condition during these 2, 3, 4, or 5 years that no case or treatment should have been done for the pre-existing condition for it to be covered. This is relevant if you have any pre-existing disease at the time of taking the policy.

7. Individual policies for family members versus family floater: We strongly recommend an individual policy for the reasons mentioned in detail on the link http://www.apnainsurance.com/health-insurance-india/indiviual-floater.html

Briefly it is because in most cases the so-called lower premium advantage of a family floater is negated once the age of the oldest member reaches 45 years or so. The other big reason is the lack of history for other members when the eldest member reaches the maximum age of renewability or the eldest member expires.