Health Insurance Portability

After mobile numbers, it is time now for the health insurance policies to turn portable. Uptil now, only motor insurance policies enjoyed this benefit in the insurance industry. With its new set of guidelines, IRDA has finally kicked Health Insurance Portability in from OCT 1^st this year. A much talked about phenomenon but scarcely understood! As is the literal meaning, your policies can now be carried/moved with ease from one insurance provider to the other. The system to share and transfer data of the policyholders is at last in place, clearing the deck for regulator, companies and customers to begin the process. Dissatisfied policyholders, for long, have had no choice but to stick to their existing insurance provider for the fear of losing benefits. They can now continue enjoying the existing benefits while relocating -

• Credit for the waiting period benefits accrued with the previous insurer for the pre-existing disease. 
• No claim bonus carried forward.
•  Possibility to convert from Group mediclaim, such as the one provided by the employer, to individual health policy. A year after such migration, transfer to any other non-life insurer.

All you have to do is apply to the new health insurer at least 45 days before the premium renewal date of the existing policy. This ensures that the new insurer has reasonable time to verify history of claims which shall be available on common database to all insurers. Strictly adhere to this rule, for the insurer will not be liable to offer portability if the policyholder fails to do so in the prescribed time. However, you can switch your health insurance policy to another insurer only if you have held the policy for a minimum of one year. It is important for everybody to be clear as to how the system will work as there are more than 50 companies who are engaged in health - which includes life, general and specialist health insurance companies. This step will not only help policyholders by giving them a wider choice and providing the insurance providers the impetus to focus more on customer value and engagement, but will also benefit the insurance industry in the long run by bringing in more transparency and allowing them to assess the risk and provide underwriting at the point of sales.

 PROCESS : On receipt of application for portability, the new health insurer shall furnish the portability form along with proposal form and other relevant product details. The policyholder has to fill in all the forms and submit the same to the new insurer. Within 7 days of receipt of the completed portability and proposal form, the new insurer, if required, can ask the existing insurer additional information about the policyholder in the prescribed format. The existing insurer is bound to provide such data within 7 days of receipt of such request. Based on the information received, the new insurer shall decide to issue health cover to the policyholder. In case, the new insurer does not communicate its decision within 15 days, then it is assumed that the application has been accepted and later on it cannot reject such application.

Where on the date of renewal of existing insurance policy, the outcome of acceptance of portability is still pending with the new insurer:

• If requested by policyholder, the existing policy shall be allowed to be extended for a short period (at least one month) by accepting pro-rata premium for such period.
• The existing policy shall not be cancelled until such time a confirmed policy from new insurer is received or if otherwise instructed by the policyholder.
•  The date of commencement of risk of the policy issued by new issuer shall match the date of expiry of the short period in such cases, and
• In case, for any reason, the policyholder subsequently chooses to continue the cover under existing insurer, it shall be allowed to continue by charging a regular premium and without imposing any new conditions.

Thus, it can be seen that ample safeguards are provided in the guidelines to ensure that the policyholder has adequate options and is not without cover at any point of time while the portability is in progress.

This move is expected to increase quality of services and encourage healthy competition among health insurance firms.

Avoid getting Trashed

The most critical moment in the entire tenure of an insurance policy is when a claim is filed. “Rejection, of any kind hurts.”In an insurance claim, the blow is multitudinal – financial, emotional,  physical - thus making it more stressful.

“One of the most common queries we get from people buying a policy is whether the insurance company will honour the claim,” says Rahul Agarwal, founder, Ideal Insurance Brokers (P) ltd., a reputed insurance brokerhouse across the country.

I was diagnosed with vertigo, a type of dizziness, this May. This is not all. The real trouble started after three days of hospitalisation when the TPA of my health insurer deprived me of the cashless claim facility. Though the insurance policy had promised me cashless hospitalisation, I had to pay the bill of Rs. 39,000 from my own pocket.

The TPA refused on absurd grounds like the illness could have been due to some pre-existing ailments and that they needed time to scrutinize the claim. However, when I referred to medical professionals, they told me that my illness had nothing to do with my cardiac ailment which was declared as pre-existing in my health Insurance policy.

While the denial of the cashless facility didn’t necessarily mean repudiation of the claim, it did shake my confidence in the insurance company. I, who has been paying around Rs 18,000 every year since 2009 as premium to the Health Insurance Co., felt cheated.

The figures of claims rejected/ pending as of today would definitely make any policyholder dubious about the efficiency of his insurance cover. But this is only half the picture. The no. of claims settled is no less. The stringent procedure followed to settle Insurance claims is to ensure that only genuine claims are paid. In fact, if Insurance companies show leniency and keep accepting bogus claims, it may cost customers more in the form of higher premiums. It is thus the duty of the policyholder to follow all policies and procedures given in the insurance document and not give the insurer any chance to reject his claim – health or otherwise.

Here, I list some broad reasons why our insurance claims may be rejected and ways to steer clear of them –

Reason:	Solution:
NON-DISCLOSURE, partial  disclosures and wrong disclosures of significant facts such as age, nature of occupation, income, existing insurance policies, major ailments or pre-existing medical conditions.	Full Disclosure. When applying for the product, understand the consequences of concealing or giving incorrect information.
LACK OF KNOWLEDGE regarding covers and exclusions under the policy. We are not even aware when breaching a condition mentioned in the policy document.	Go through the policy terms and conditions and understand them well before purchasing. When in doubt, seek clarifications from the advisor.
DISCREPANCY IN PROPOSAL FORM because we often refrain from filling our forms and depend on third parties. They are often not aware of details and an imp fact might be inaccuratly represented.	Fill up the proposal form yourself. Submit genuine documents in an orderly and timely manner to the insurance company with details. If any discrepancy is found in the policy, immediately get it rectified.
SURPLUS EXPENSES. Private hospitals, in their quest to generate maximum revenue, sometimes perform medical procedure which may not be necessary. In motor, usually bills are blown out of proportion. These irregularities, when caught by the insurer, results in rejection of the claim.	Avoid extra costs. Make sure the medical process undergone was necessary. Do not include motor repair charges of pre-existing damages or costs not covered under the policy in the claim.

Use multiple plans efficiently

It’s not uncommon for an individual to be covered by two, or even three, health insurance policies. One reason for this is the rise in the cost of health-care services in the past decade. Ten years ago, a Rs. 2 lakh health insurance cover was considered fairly sufficient for an entire family. Today, it will barely be enough to pay for a five-day stay in a hospital. Also, medical insurance cover from employers is not sufficient. In both circumstances, one has to buy another policy.

            But while a larger insurance cover is a good thing, multiple health insurance policies can lead to confusion when making claim. Should a person claim only from one insurer? Does he need to inform his insurer about the additional covers? Will the hospital allow two cashless claims for the same illness? Will he get the no-claim bonus if the second policy is not invoked? It’s all quite confusing for the policy holder, who might be under strain due to the illness.

            The first things to know is that it pays to inform all insurers whenever there is a hospitalization. This does not mean that one can separately claim the expenses from each of them. “You cannot profit from a medical  insurance plan”, says Joydeep Roy, chief executive of L&T General Insurance Company. It’s only that by informing all the insurers, the policyholder is able to optimally utilize the cover available to him. The claim has to be paid by the insurers in the same proportion as their health cover. Say, a policy holder has two policies – one for Rs. 2 lakh and the other for Rs. 1 lakh. If he makes a claim of Rs. 1.5 lakh, the first policy will pay 2/3^rd of the amount (Rs. 1 lakh) while the second policy will pay the remaining 1/3^rd (Rs. 50,000).

            This sharing is subject to the terms of the policies. “There is a contribution clause in most policies. The expenses are shared by the insurers proportionately,” says Sanjay Datta, head of customer service (health and motor insurance) at ICICI Lombard General Insurance.

            You may want to know why the person would claim from the second policy. After all, isn’t his Rs. 2 lakh cover his expenses. Perhaps not, because unlike in the past, most health plans now have limits on the expenses under different heads, For instance, there is usually a cap of 1% of the sum assured on the room rent per day. So, a Rs. 2 lakh policy will only reimburse up to Rs. 2,000 a day. This means that an insurance plan may not fully cover your medical expenses(see table*) . It is also a good reason why one should study the policy features in detail, especially the fine print on benefits, before buying one.

            Financial planners advise that whenever the need for hospitalisation arises, one should inform the third party administrators (TPAs) of all the health policies held by the person. For instance, if you have three policies (one from your employer, one from your spouse’s employer an done bought on your own), you will need to mention that you have additional cover at the time of making a claim. Claim forms require the policyholder to state if he is covered under any other medical policy or group insurance scheme. “ The policyholder can choose to claim from only one insurer. If he has another policy but the claim has been made only with us, we will process  and settle the claim as per norms. Later, we can pursue with the other insurer for their share of the claim,” says Subrahmanyam B., vice president & head, health vertical, Bharti AXA General Insurance.

            However, if one of the policies has been bought recently and still in the waiting period, then the policyholder can claim only from one policy which is already in effect.

            Insurance companies require you to submit original bills and documents at the time of making claim. Since you will be claiming from more than one insurer, request the hospital to provide you with

certified duplicate copies of the treatment summary, bills and discharge slips. That’s easier said than done because hospitals are fussy about these things. If your hospital is not helpful, submit the originals to the primary insurer and attested photocopies to the others. Like we said, if all insurers are in the loop, you will not face any problem.

*Why a Rs 1 – Lakh health plan won’t fully cover a bill of

Rs. 65,000

Expense Head	Expenses Incurred	Limit as % of sum assured	Claim allowed
ICU charges (Rs. 8,000 x 1 day)	Rs. 8,000	2% per day	Rs. 2,000
Room rent (Rs. 3,000 x 5 days)	Rs. 15,000	1% per day	Rs. 5,000
Doctor/surgeon/ Anaesthesist fee	Rs. 20,000	25% per illness	Rs. 20,000
Surgery, implants, medicines, treatment and diagnostics	Rs. 20,000	50% per illness	Rs. 20,000
Ambulance	Rs. 2,000	Rs. 1,000	Rs. 1,000
Total	Rs. 65,000		Rs. 48,000

• In the above example, while some of the expenses were fully covered, the limits on certain heads such as ICU charges, room rent and ambulance service reduced the amount of reimbursement.
•  If the policyholder has another health insurance plan, he may be able to get the full claim.
•  In the case of multiple plans, insurers will bear the cost proportionately to the cover they offer.
•  Multiple health plans enlarge your cover but also makes the claim process cumbersome. You can avoid this by getting additional cover from the same insurance company.

Source: Times of India

Have you used your cashless card yet?

The concept of health insurance in India is seeing a continual improvement in the past few years. One such result is cashless medical insurance which allows the policyholder to be hospitalized without the harassment of immediate payment, especially during emergencies. You just intimate your Third Party Administrator (TPA) of your situation and avail the medical treatment. TPA verifies your policy details, on behalf of the insurer, and gives clearance for the cashless services to be processed. In case of a planned visit, you should first inform the TPA and then avail treatment under the network of hospitals. Thus the most important research here is the number of tie-ups your cashless insurance carrier has with hospitals across the country.

Needless to say, the more hospitals your medical insurance provider has in its network, the easier it will be for you to avail its benefits.

Though Insurance companies hype cashless settlement policies as customer-friendly and convenient, for many who have bought these policies, the experience has not lived up to the promise. Many-a-times the insured has to either pay the hospital himself and get it reimbursed later, or run from pillar to post for the 'pre-paid'

facility, in which case the entire essence of a cashless facility vaporizes. Reasons behind it are many, the primary ones being the ignorance of the user and the hospitals overcharging patients under cashless claims.

It is thus worthwhile to keep the following in mind, when availing cashless -

• For planned hospitalisation, send the pre-authorisation form to the TPA, at least a week before the surgery.
• In case of accidents, make sure the doctor fills in fields like time of accident and evidence of alcohol abuse. A partially filled or illegible form sent to the medical team means it will be sent back to the hospital for clarification and cause more delay.
• If you are accompanying the patient then mention your cell phone number on the pre-authorisation request to ensure that the TPA can get in touch with you immediately.
• Carry your cashless settlement card at all times. This is of significant help in case of an emergency.
• Find out which of the network hospitals is close to your house or place of work.
• Be clear about which expenses and surgeries are covered by your policy.
• Don't forget to renew your policy every year.

Can the Insurers walk out of contracts mid-term?

According to the regulations, a policy can be cancelled only if there is a case of fraud, misrepresentation or non-disclosure of material fact from the insured.

But, few corporate have faced the problem of cancellation in their group health in the mid-term because of high claims, which according to IRDA isn’t allowed.

There were a series of complaints from group health insurance customers which lead to this move by IRDA. A circular has been issued to all the companies stating that insurance policies cannot be cancelled mid-term.

Both the insurance industry and the insurance policy holders have their own stand on the decision. According to the people in industry, after giving enough notice to make alternative changes, including cancellation clause has been a regular practice internationally and historically. Plus, in the cases where cover has been provided on the basis of reinsurance, it is important to have a cancellation clause because the reinsurance companies have the similar clause.

But again, there are different views as well. If we think from the side of the policy holder, he takes the policy trusting that his claims will be settled. Just to increase the top line, insurance companies should not overlook the risk involved with the client. A proper underwriting should be done before the policy is issued to the client.

So, what is your take on the issue? Do you think IRDA did the right thing?

Source: Times of India

Good news for those who believe in non-allopathic treatment :)

As we are aware, most of the health insurance policies only cover allopathic treatment but other form of treatments like ayurveda, homeopathy, etc were not covered. And we all know that, now days people are moving to these so called ‘less harmful’ form of treatment esp when it comes to chronic ailments like spondilytis, arthritis and epilepsy but again even these treatments are not very ‘cheap’.

So for the relief of those, few insurance companies have included such alternative forms of treatment under their cover, especially ayurveda. Though it has been limited to individual or govt. scheme or corporate policy from company to company but yes the first step has already been taken. And ofcourse, there are limits on the amount which can be claimed.

Naturopathy treatments are excluded in all policies, while few cover unani and homeopathic. This is because other forms of treatments have no standard treatment protocols and highly varied costs thus making it difficult to actuarially compute the cost to be covered. Even under ayurveda, select procedures are covered to ensure people do not misuse a policy for a basic rejuvenation procedure.

It is important to note that there is no standalone cover available for covering alternative treatments. You will have to buy a standard health insurance cover from these select insurers and others who start offering the non-allopathic coverage.

Before you head for alternative treatment and make a claim, see whether the treatment is listed in the insurance policy document. Insurers are particular about the specific treatments covered.

Source: Economic times

Waiting period for Health Insurance

Did your claim got rejected because your disease was not covered in the first 2 years of the policy??

Are you suffering from some Pre Existing Disease and want to cover the same??

There are many diseases like Appendicitis, Hernia, Cataract, etc for which an individual can delay the treatment. Many people apply for a policy after discovering they are suffering from one of these diseases. So to avoid such intentional claims, the Waiting Period clause is there in All Health Insurance policies in India.

So, when you sign up for a new health insurance policy, it doesn’t get implemented with immediate effect. The policy comes into effect after a ‘waiting period’, which depends on the kind of insurance and factors such as

·         The nature of disease

·         Your medical history

·         The Insurance company

·         The Insurance Policy Chosen

In other words, the insurer is liable to entertain any claim amount filed only after this waiting period. If an individual undergoes an accident or undergoes hospitalization during the waiting period, the customer may not be covered for a loss.

 

As mentioned before, the concept of waiting period exists across different kinds of insurance policies, and the quantum of waiting period may differ depending upon the insurer and the nature of the insurance policy. However, following are the broad indicators of waiting period.

1)      There is an initial waiting period of 30 days during which no claims is entertained (except maybe an accident case where it has to be proved the accident happened after issuance of policy)

2)      There is an initial waiting period of 1-2 years for diseases like Appendicitis, Hernia, Cataract, Gall Bladder or Kidney Stone, Piles, Tonsillitis, etc

3)      Pre -existing diseases are normally not covered till 4 years of the policy. Previously pre existing was not covered at all. However, now IRDA has made in mandatory for Insurers to cover pre existing after 4 claim free years. In fact, some insurers are also covering pre existing after 1 year like the Varishtha Policy of National Insurance

4)      Diabetes and Hypertension can be covered in many policies from Day 1 on payment of extra premium. Else Diabetes will fall under the Pre Existing Clause

5)      Maternity can be covered in companies like Apollo DKV and Max Bupa after a certain waiting period too

A pre-existing disease refers to any medical condition of an individual prior to the commencement of the policy. Now the policy may be effective for any other ailments in the first few years of the policy. Buy any claim filed for illness related to the pre-existing disease will not be covered in the first 1-4 years of the policy as stated in the policy document. This feature is most common in insurance policies designed for senior citizens. Also, the insurers may insist that you stick with the same insurer if you want the cover to continue without further waiting periods in future.

However, when a corporate takes a Group Policy for all its employees, they can customize the policy to remove the “waiting Period” clause and even “pre existing” disease or “maternity” can be covered from the first Day of the Policy.

For more details, feel free to mail to our Health Insurance Help Desk at health@healthandinsurance.in or call at (+91) 98 30 01 23 88