Rightful Claim and Speedy Settlement

Any insurance policy is taken out with the sole motive of availing the claim when it arises. To ensure that insurance co.s do not find a way to go around this on the pretext of delayed submission of documents, the Irda has sent a circular to all insurers clarifying that they cannot deny any claims if the delay is due to unavoidable circumstances. The regulator said that the insurers' decision to reject a claim should be on sound logic and valid grounds. Rejection of claims on purely technical grounds in a mechanical fashion resulted in policyholders losing confidence in the insurance industry, giving rise to excessive litigation.

At present the claim to be considered valid, has to be intimated to the insurance company in a prescribed form within 7days. After the claim is registered, the company will give a reference number that needs to be referred to in all future communications. The insurance company will then, carry out investigations, loss assessment and provisioning and make the final settlement.

The circular says insurers need to develop a sound mechanism of their own to handle such claims with utmost care and caution. It does not put any penalty on the insurer for rejecting the claim. The regulator also mentioned that the insurers are advised to incorporate additional wordings in the policy documents and must not repudiate claims unless the reasons for the delay are specifically ascertained and recorded. 

The insurers should satisfy themselves that the delayed claims would have otherwise been rejected even if reported in time.

To make claim settlement faster, the policyholder is to fill the claim form, which has details like basic information such as policy number, name of the insured, date, place and reason of hospitalisation or death and the name of the claimant, and submit all relevant documents such as hospitals bills, original death certificate, policy bond, police FIR, postmortem report, certificate and records from the treating doctor/hospital, etc. to the insurer as soon as possible. One should always keep a photocopy of all the bills and the filled claim form for records. Under the regulation 8 of the Irda (Policy holder's Interest) Regulations, 2002, the insurer is required to settle a claim within 30 days of receipt of all documents including clarification sought by the insurer. If the claim requires further investigation, the insurer has to complete its procedures within six months from receiving the written intimation of claim. However, some complicated third-party claims can take years for settlement. The claim amount is either sent through a cheque or remitted to the bank directly.

Basal Metabolic Rate

BMR is an estimate of how many calories you would burn if you were to do nothing but rest for 24 hours. It represent the minimum amount of energy required to keep your body functioning. Here’s the formula for calculating your BMR:
BMR = 655 + (9.6*weight in kg) + (1.8*height in cm) (4.7*age in years).
So your daily calorie intake to maintain your weight should be: BMR*1.15. To lose weight, cut down on this calorie count significantly.

WHAT IS METABOLISM?
Metabolism is the rate at which your body burns calories. Calories are burnt even when you’re sleeping and eating, because you need energy to keep you going. It differs for everyone. Factors such as muscle mass, genetics, overall weight, age and fat content determine how fast or slow your metabolism is.

HOW CAN YOU REV IT UP?

• Eat sensible, Eat healthy. Most people think that the thinner a person, the better her metabolic rate, and that this gives her a license to go on a junk food binge. Junk, oily and spicy food can slow down metabolism because these foods are tougher to digest and they add more to the fat content than to energy levels.
• Exercise will hike your metabolism levels simply because your body needs to burn more calories to sustain itself during and after a workout. “People must exercise for at least 30 minutes daily,” says a dietician. “An increased metabolism also helps in faster digestion, so even an occasional heavy meal does not make you feel bloated like it normally would if you work out.”
• Sleep like a baby. People who sleep less than seven hours a night cause their systems to slow down the next day-reflexes become sluggish and food is digested slower.
• “People do more cardio exercises because they think only these help in weight loss,” says a gym trainer. “But lifting weights and building muscle mass also causes calorie burn and weight loss.”

DON’T TAKE YOUR METABOLISM FOR GRANTED
A common misconception among people is that thin people have a high metabolism. People with high metabolism aren’t necessary thin. If you have a high metabolism, it only leads to a bigger appetite and higher calorie intake. Even the fastest metabolism hardly burns a maximum of 3000 calories in a day. So a high metabolism is of no use if you are eating more than what your body is burning.

WHAT FACTORS INFLUENCE YOUR METABOLISM?
There are some factors that you can control and change, and some factors that you can’t.

Age: Metabolic rate decreases by 5% with each decade.
Gender: Men generally burn calories more quickly than women because they have more muscle tissue.
Heredity: You can inherit your metabolic rate.
Thyroid disorder: Hypothyroidism and hyperthyroidism can slow down or speed up metabolism, but only 3% and 0.3% of the population have them respectively.

Source : Femina, oct 2011

Choosing the Right Health Plan

Are you caring for any dependents? Do you have any pre-existing conditions? How comprehensive do you want your plan to be? Do you need dental and vision plans? Do you have a chronic illness that requires monthly treatment? What are your month-to-month medical expenses, like prescription drugs? What could happen should you require surgery? What if you were injured in an accident? How much preventative care do you want?

Given the plethora of questions and options in the health insurance space, it is difficult to make a rational choice. One person who can rationally help you find the right health insurance plan is your insurance broker since he would be aware of the latest health insurance products in the market and he has your best interest in mind. It is finally up to you to make an informed decision based on his suggestions.

With insurance going online, getting health insurance quotes has become even simpler. No longer do you need to call up several insurance companies or fill out various different applications for getting health insurance quotes. On sites like healthandinsurance.in, all that you need to do is – enter in your requirements and you will be easily able to compare benefits and costs from different insurers.

Selecting a health plan is a matter of balancing the cost of a plan with the amount of coverage you need, the degree of choice you want and the trade-offs you are willing to make. Fueled by the skyrocketing costs of health care, revolutionary changes have been taking place in the design of health plans to reduce costs while maintaining quality care. There can thus be no dispute over the need for health insurance. Some points that specially needs to be noted are -

 

Cashless & reimbursement plans
There are two options available. The first is the cashless policy where you don’t need to pay while getting the medical treatment done.The payments are generally done by hospitals through their tie-ups with third party administrators (TPAs). Then there are reimbursement plans where you have to pay at the time of getting the treatment done and then are supposed to apply for reimbursement from the insurance company.

Difference in premium
How much health insurance will cost you depends on your age, the condition of your health, where in the country you live, your income, your job status and the like. When comparing policies, make sure you are comparing the same benefits and coverage. Also check the co-pays or coinsurance, deductibles and waiting period.
The deductible is the amount you must pay out-of-pocket before any medical charges are eligible for reimbursement. Plans with the highest premiums usually have low deductibles. When you choose a plan with a higher deductible, the premiums are usually lower.
Co-insurance is the percentage of covered expenses that you will pay. For example, co-insurance on office visits may be 70/30. This means the insurance company will pay 70% after the deductible, and you will pay 30%.
You will have to serve a waiting period when you start a new health insurance policy or increase your level of cover. There are also waiting periods for particular diseases.

Tenure of the cover
The mediclaim has to be renewed annually and within the specified time.


Size Matters
You should look at the annual limit of your health insurance policy. According to experts, if you hail from a small- or mid-sized town you should look at a cover of Rs 2-3 lakh. If you reside in a metro, then you should not look at covers less than Rs 4-5 lakh.

Clause On Sub-Limits
There are sub limits in mediclaim policies, the most common of them being room rents, doctors’ fees and diagnostics. If you have a sum insured of Rs 1 lakh and the insurer has capped your room rent at 1-1.5% of the sum insured then your room rent cannot exceed Rs 1,000. If it exceeds the specified amount, then you have to pay the balance from your pocket.

Other Clauses

There are mediclaim covers which do not cover pre-existing diseases for four years whereas some which do not cover it for three years. Similarly, ensure there is no ambiguity in the renewal clause of the policy. Another clause is the limit on Pre-Post i.e.expenses which include commuting to the hospital, buying medicines post hospitalisation and so on.

Other Information

Go through the list of hospitals and other facilities you would be able to use under the insurance plan. Equally important is to understand the plan’s procedures for handling claims and complaints.

The Ideal Choice

Keep in mind that there is no one-size-fits-all health insurance plan. The needs of a healthy 20something are vastly different from the needs of a family of four, which are vastly different from a baby boomer entering retirement. Right health insurance can save you from multiple expenses when it comes to paying for emergency or long term health services. Once you’ve settled on a plan, it is imperative to thoroughly understand it and follow its guidelines. And don’t forget you always have the option of claiming a tax benefit of up to Rs 15,000 under Section 80D.