Your health insurance queries answered

Have a query regarding health insurance or mediclaim policy? Maybe we can help.

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.

My wife got operated for Tubal pregnancy (when the baby starts growing outside the uterus). During the operation, it was decided (on the spot) that one of her fallopian tubes would have to be removed for safety. Both the pregnancy and removal of tube were established on consecutive days with the surgery defined by doctors as medical emergency.

Can I get a mediclaim for the above purpose as I have been told that maternity and pregnancy related issues are usually not covered for claim?

Harsh: Yes, you are right that maternity and pregnancy related issues are usually not covered for claim. But the judgment given by Delhi Consumer Commission clearly contends that "ectopic pregnancy" ailment does not fall under the category of normal pregnancy issue, and has awarded compensation to the claimant.

Under this clause you can definitely file you claim for reimbursement with your insurance company.

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I would like you to suggest the best health insurance policy under floater benefit for my wife aged 39 years and mother-in-law who is solely dependent on me. I don't require one since my company (PSU) provides full compensation and benefits.

Harsh: Dependent in-laws are not covered under family floater plan. It would be advisable to make separate mediclaim policy for your mother in law. If you mother in law is a senior citizen, then you can buy a mediclaim policy specially designed for senior citizens.

It is advisable to take your own health insurance policy, even though your company provides you group mediclaim policy. You never know when it will be needed.

In this regard you take a family-individual mediclaim policy for minimum sum insured of Rs 3 lakh.

Following are the premium quotes for an individual aged between 39 to 43 years, looking for family individual plan for sum insured Rs 3 lakh each.

For your in-law it would be advisable to take individual health insurance plan. Depending upon her age and medical history she can take a suitable policy.

You can also log into our website http://www.apnainsurance.com/health-insurance-india/comparison.html for analysing various insurance company with premium quotes and other related features of the plan.

I have a mediclaim policy with Oriental Assurance for the past 6 years. My agent suggested me to switch to New India Insurance.

This is what my agent told me:

• I am eligible and get no-claim bonus
• Pre-existing diseases also covered even if I switch my company
• I could increase my policy amount from Rs 1 lakh to Rs 2 lakh and he told me that the maximum amount of my policy could be increased to Rs 1,75,000.

Is the information provided by my agent correct?

Harsh: The information provided by your insurance agent could be correct. But the point is at this point of time when you have already completely 6 years of policy term, just because your agent is proposing you to switch over, it make no sense.

Now that you have already completed 6 years of policy term with your Company, you are automatically covered for pre-existing diseases.

On your renewal date you can definitely increase your sum insured to the maximum permissible level. So it would be advisable to remain with existing insurance your plan.

I am a retired executive with no income other than my savings. Since both my kidneys have failed due Autosomal dormant polycystic kidney disease, I have to undergo dialysis 3 times a week. My son, an engineer, works for an MNC and his company has taken a policy wherein I am also covered for pre-existing diseases.

They have settled one claim but have subsequently rejected the next claim. The grounds are genetic disorder hence not admissible under clause 4.15.

The illness was diagnosed only a few years ago and I have commenced dialysis only in Jun 2009. I am 58.

Harsh: The claim is rejected on the ground of clause 4.15 of permanent exclusion under group medical insurance policy. So cannot do anything about this.

How does the insurance company calculate 'Loading charge' on the premium for next year's premium if your claim is within the limit of total sum assured?

The insurance company is New India.

Harsh: There are many policies which do not have a method of calculating the loading but still mention in the policy wordings that they may load the premium in case of adverse claim experience. This is very dangerous as the loading can be anywhere from 5 per cent to 100 per cent of the premium and the customer can do nothing about it.

I would like to purchase a mediclaim policy for my family. I am 30-year-old and spouse is 27. Which company will be better in case of reimbursement, cashless facility and should include major critical illness.

Harsh: All insurance companies would reimburse your claim provided all the necessary claim settlement procedure is followed as per the respective insurance company standards.

So whichever health insurance plan you take, do go through the policy conditions pertaining to the exclusions, claim settlement, and so on.

Premium quotation for family individual plans for self and spouse.

I had purchased a mediclaim policy under platinum policy conditions of United India Insurance Co. Ltd. in the name of my 18-year-old son on December 9, 2009.  On May 10, 2010 he was admitted to hospital and Laproscopic Tanners operation done on 11.05.2010.

I have incurred hospital expenses of Rs 80,000. The TPA, saying the disease was since his birth, rejected my claim. Is there any chance of revision of this decision if I approach the insurance company, since till the age of 18 there was no symptom of the disease?  Please advice.

Harsh: To prove your son's stated disease is not congenital disease, you need to consult your doctor who will examine your son.

The doctor's examination report will prove whether your son is born with the stated disease or not. If the report is negative you can log in a complaint on the official web site of the company.

If they don't Harsh to you within a period of 2 to 3 weeks, please approach insurance Ombudsman with your complaint and they will look in to the same. Approach the insurance company for the revision.

I am Rahul Dusane. My father has a mediclaim policy from United India. A few days back my mother (aged 52) went through a Hystectomy operation at Bapat Hospital, Thane.

I was charged Rs 75,000 for this operation. But as per mediclaim officers for this particular operation there can be a bill of maximum of Rs 50,000. Now I have already paid the balance amount to the hospital (apart from the pre-approved amount from United India of Rs 50,000). What can I do in such case?

Harsh: In this case you can file a complaint with the insurance authority for the transaction game played by the hospital and the insurance company.

I am a mediclaim policyholder since last 20 years and I have not claimed since I applied for this policy. Now I am staying in USA since 1998 and I am regularly renewing mediclaim policy annually.

I want to know if I am staying in the US since the last 12 years, can I get mediclaim coverage?

Harsh: Mediclaim policy will only reimburse your medical treatment taken in India. Indian insurance company will not reimburse any hospitalisation expenses incurred in USA. But if you still have ties in India and come here often, we would recommend you to continue with your policy.