Consumer Education


Qus. I bought a term insurance plan of Rs. 50 Lakh in 2010. My salary has increased and I want the amount to be Rs. 90 Lakh. Should I buy another term plan of Rs. 40 Lakh or is there a way to increase the amount in the existing plan? Which will be cheaper?

You have no option but to buy a new policy. As there is good competition among Life Insurance Companies you can contact a good Insurance Brokerage Firm and get a good economical product. Other terms remaining equal 2 policies is a better bet as consolidating into a new policy of Rs. 90 Lakhs may have negative point. In the event of lodging of claim for Rs. 90 Lakhs in first 3 years of new policy your nominee may face difficulty in claim settlement.

Qus. I bought four endowment plans four years ago and the total premium outgo is Rs. 60,000. I recently realized that term policies are cheaper? Should I stop the four plans and go for a term plan?

Do not do it – take long term perspective and go on paying.

If possible you can buy term insurance policy with premium of Rs. 20,000.

Qus. I paid premiums for my policy for 17 years and then stopped paying since January 2007. I would now like to pay the premium and make my policy active. How do I do that?

Approach your insurance company. They should definitely be keen to help with something which will be in your interest.

Qus. My father gifted me a painting by M.F. Hussain 20 years ago and it must be very valuable now. How can I insure it?

Get the painting valued by a valuer (on the approved list of Insurance Company and get it insured. Contact a good Insurance Brokerage Firm (Ria Insurance Brokers Pvt. Ltd – and they can advise you. A word of caution – you have to put in effort to get this policy. It is not easy to buy.

Qus. I have a health insurance policy that also reimburses outpatient (OPD) charges and medicines. I want to know if it will also cover homeopathy or ayurveda treatment. If not, can a special rider be taken for these covers?

There are a few options available – example: Star Health covers homeopathy in post operative treatment (after returning from hospital) HDFC Ergo covers 20% of Sum Insured provided you are treated in approved Ayurveda hospital.

No you cannot take it as a special rider.

Qus. I am buying a new car. What are the types of vehicle insurance available? This is my first car and I am new to driving.

We are assuming that you have learnt driving in a good Motor Driving School and have got Driving Licence.
Our Suggestion is that you go in for an old car. After driving old car for few months, you may go in for new car.
Broadly speaking Vehicle Insurance is divided into 2 parts:

  1. Own Damage (OD)
  2. Third Party (TP)

OD is your choice, but TP is mandatory in India and you but it.

Qus. I pay an annual premium of Rs. 3.5 Lakhs for my LIC policies. Can I get these policies converted into online plans to save on the commission being paid to the agent?

It is not possible for existing policies. For policies that are existing, the charges will stay the same whether you pay online/ cheque/ cheque through advisor who sold the policy to you.

Qus. I plan to go abroad for eight months. My travel insurance policy has some mistakes in spellings and passport number, what should I do?

You must get the name/ passport number corrected as it will be used for claim settlement. You can have serious problem due to this mistake. Generally overseas Travel policy is issued for maximum period of 6 months. You should check that it is for 8 months.

Qus. I recently bought an apartment. Does it make sense to go for home insurance individually? If the whole building comes down, will the insurance company pay me individually? Or is it only the association that can go in for insuring the entire apartment?

Yes it is sensible to have home insurance which should cover

    • Structure
  • Contents – furniture/ clothing/ electrical appliances/ refrigerator/ Air conditioner etc.

Yes – you will be paid for sum insured by you. Your association can go in for the insurance of the structure/ common area, boundary wall, DG set, Lift etc. There can be difference of opinion among members of association as due to value addition/ renovation different flat owners may perceive different value for the flat.

Qus. My age is 38 years. I want to have Life Insurance for Rs. 25 Lakhs but I am scared of Medical examination. What is the option?

You can go in for Aviva Life Shield Advantage, which has the benefit of

a) Term Insurance
b) Return of Premium on expiry of the policy

In this policy no medical examination is required for those who are in age group of 36 to 45 years provided sum assured is Rs 25 Lakhs or less.

As you are looking for sum assured of Rs 25 lakhs –you would be eligible for the policy.

Qus. I am 28, working in a private company with monthly salary of Rs 25000. I am looking for a health policy with cashless hospitalization facility, which would cover my wife and my parents.

You have a wide choice. Depending on age of your parents you can choose suitable one. Out of many options some are:-

  1. Oriental Health Family Floater – all of you can be covered in one policy.
  2. Max Bupa Heart Beat Family First – all of you can be covered in one policy.
  3. Another option is to get 2 separate policies issued.
    • Policy 1 – You/ Spouse + Children
  • Policy 2 – Your Parents

The decision will be based on premium/ features which are dependent on the following considerations (amongst others):

  • Age of your parents
  • Sum assured you are looking for
  • Any preexisting disease any family member is having.
Qus. I have three unit- linked Insurance plans or Ulips- total sum assured is Rs 35 lakh. A friend is asking me to buy another endowment plan, which gives a cover for life. Should I buy?

No, you should not buy. It will be better for you to buy term insurance of say Rs 50 to 100 Lakhs. This will provide good security to your family, which would be helpful for them.

Qus. My brother suffers from asthma. Will life insurance be expensive for him?

He should reveal this fact in the proposal form and let insurance company call for medical examinations. Do not hide the facts. While the Life Insurance Company may add a loading on the premium based on the facts, this is better for you as it protects you interest i.e. there can be no repudiation of claim, when lodged.

Qus. I am 46 years old and own 50% shares in a private limited company with a turnover of Rs 10 crore. I draw Rs 50 lakh per annum. Should I buy a term plan or Keyman Insurance?

If both partners are ready then you can go in for Keymen Insurance for both of you. You should keep in mind that in the event of claim money will be given to your company and not to your nominee.

Qus. I am 35 years (self employed) old with a wife, 2 children, and need to support any parents (both diabetic at age 64 & 61 Years). I am considering buying a health insurance policy to cover the medical expenses of my family. I am considering buying a family floater health plan, which I believe covers the entire family for a low premium. Please advice?

You can consider Oriental Happy Family Floater where all of you will be covered and that too at an attractive premium.

The other option will be to go in for 2 policies
Policy 1 – Parents
Policy 2 – For your family

Our suggestion is that you should go for higher amount for your parents with coverage for diabetics. As far as you are concerned, you will have the opportunity to increase sum assured as the time passes.

Qus. I am a 22-years old, single and I would like to know whether I should go for a normal health insurance or a term plan. Some of the companies claim paying Rs. 50,000 pa will get me a return of 65 lakh after 30 years and with a cover of 12.5 lakh in this period?

It seems you have mixed up 3 different policies :

  1. Health Insurance
  2. Term Insurance
  3. Endowment Life Insurance

Under Health Insurance – your hospitalization needs will be fulfilled; Under Term Insurance – your nominee will get sum as per sum assured.You will get nothing if you will survive till the maturity date of Term Insurance Policy Under Endowment Life Insurance, you will get sum assured with bonus declared by the insurance company during 30 years. The exact calculation can be done after allocating funds out of Rs. 50000 for policy no 1 & 2. Broadly speaking if the sum assured is Rs 12.5 lakhs you will not get Rs 65 lakhs.

Qus. Can Life insurance policy be transferred to another person?

Life Insurance policy is issued to an individual on the basis of his age, occupation, health etc. This cannot be transferred to another person. In every policy it is essential that you nominate one of your family members to be the nominee, who will get the benefit in the event of any mis-happening.
You can use your insurance policy as collateral with a bank in which case you will have to assign your policy to the bank. This is called assignment and ownership of policy will be transferred to the Bank. After the loan is repaid the policy will be assigned back to you.
In some countries you can sell your insurance policy at an Exchange (like stock exchange) before maturity and get better value than the surrender values. These are called TEP or Traded Endowment policy to be given to you by the life insurance company.
In India, you cannot assign your life insurance policy to anyone. However, it is best to check up the rules with Insurance Company.

Qus. My mother is 73 years old. I would like to take term plan for her but do not know which insurance company to approach. Is there any company which can offer term plan to her? Also can she buy health insurance?

Yes you can buy Term insurance policy, for her form IDBI Federal Life Insurance which offers term plan upto entry age of 85 years. In the unforeseen event of demise in the first two years of the policy, 125% of total premiums paid shall be returned. After two years, she will be insured for the amount of sum insured for life. The amount of premium and cover remain the same throughout the life of the policy, except after age 90. At age 90, the premiums will stop, but life insurance cover will continue.

She can also buy health insurance. from Max BUPA the only company that provides health insurance to person of any age up to Rs. 50 lakhs insurance cover. Premium payable for coverage of Rs. 10 lakhs will be Rs. 81,747.

Qus. I pay Rs.2 lakh a year as insurance premium. My fund value is still negative and if I surrender now, the initial amount of Rs.2 lakh would be forfeited. Is there any way I can get the surrender value inclusive of the initial premium?

No, there is no possibility to get surrender value inclusive of the initial premium.
You should pay premium for minimum number of years or be prepared to accept loss.

Qus. What happens when I cancel the health insurance policy?

If you cancel the policy within 15 days of receipt of the policy, then you are returning it under look in period then you get 100% refund. In case you had paid fee for medical tests then it will not be returned.

Qus. I am young and healthy. Do I really need health insurance?

Health Insurance covers hospitalization due to illness and accidents. No one can say when a young & healthy person may need hospitalization due to illness, accident or swine flu or due to dehydration caused by food poisoning. It is always good to have health insurance policy, which takes care of you & your family members. Your parents and parents in law should also have suitable Health Insurance policy

Qus. Is it alright to take health policy online or is it advisable to take it through some insurance brokera ge firm/ agent?

Buying of the policy is the beginning of your relationship with the Insurance Company. It is always better to buy it through insurance intermediary. If you buy it through an agent then you will get through him true information of one company. If you buy it through an insurance brokerage firm (IBF) then you will get better choice as IBF represents all the companies and gives a better choice – you get right product from right insurance company at right price. When claim is being lodged then the IBF will help you in getting the claim settled.

Qus. How to choose the right policy?

First rule is that you should choose the sum assured while looking at what your pocket can afford. Keep in mind that in most of the policies there is condition of room rent limit on per day basis. It is 1 % of the sum assured. In case you are assured for Rs 2 lakhs then room rent to be paid will be Rs 2,000 per day. In a good Delhi hospital this rate may be Rs 6,000 per day – it means that if you stay in hospital for 3 days then under the head of room rent Rs 18,000 will not be paid to you but only Rs 6,000 will be paid.

Qus. How is the premium determined in Health Insurance ?

It depends on the age, sum assured, whether person to be insured has any pre-existing disease or adverse health conditions. The rates are fixed and are available in the brochure published by the insurance company.

Qus. My employer provides me with health insurance coverage. Is it advisable to take another policy on my own ?

If the sum assured is good and the company is doing fine then you should think positive and do not go in for additional sum. When you plan to leave the organization then you must verify from the new employer whether they have suitable sum assured available for you as part of compensation package. If no health insurance is available then you must buy Health Insurance immediately so that 30 days cooling off period of new policy (purchased by you) is matching with last 30 days with your employer. Try to have this health insurance from the same Insurance Company.

Qus. What is the difference between health insurance and mediclaim ?

Both the terms are inter-changeable. Mediclaim was the term being used by PSU’s since 1986. With the entry of Private companies in 2001, the term Health Insurance got evolved and the same is being used.

Qus. Can you transfer your existing family floater policy to some other insurer and still expect the bonus to continue ?

It totally depends on the Insurance company. Believe in what is given to you in writing as a part of policy language. Insurance company will only honor what is in writing.

Qus. What is the basic difference between individual and group health insurance coverage ?

Individual Health insurance is what you buy as a family of 1 to 6 persons. Oriental Insurance is the one which gives Oriental Happy Family Floater Policy, where a family of upto 10 persons can be covered. Group Health Insurance policy is what is issued to a corporate or a group or to an association and covers a group (generally more than 100 persons). The positive point in a group policy is that you can negotiate special terms like;

      • Maternity coverage is available
      • Pre existing disease is covered
      • No medical examination, even if you are above 45 years

    When a member leaves the organization you can add the new member as a substitute for the one whose name is deleted. Rates in the case of a group policy can be attractive. For very large group of say 1,00,000 the rates are very attractive.

Qus. Why should I buy Overseas Travel Insurance ?

Indian health Insurance policy is valid within India. If you are traveling then you may need medical attention – this is only covered under Overseas Travel Insurance Policy. In addition to hospitalization medical consultation is also covered. Baggage Loss/ Passport Loss/Delayed Flights are also covered.

Qus. What problems can you face when you change your health insurer and try claiming money for hospitalization charges for treating pre-existing ailments ?

The new Insurance Company will not pay for pre existing disease. You should continue with the existing insurance company as it is legally bound to pay for future hospitalizations with same disease. It is a safer bet for you.

Qus. Can my health insurance carrier continue to raise my premium rates ?

Yes, Insurance Company has the right to refix the rates. During April 2010 Reliance General has increased rates by 170% to 221%.

Qus. Can health insurance companies deny my application for individual insurance due to a health condition?

Yes. They can either refuse or issue the policy with loading (which means extra premium). You do not have the right to compel the Insurance Company. If you are above 45 Yrs and have paid for medical tests even then you do not get the right that they must issue the policy.

Qus. If I change from one individual health policy to another, can the company impose preexisting condition exclusion on the new policy?

Yes .If you had lodged claim with earlier company then new company will treat the disease as pre existing disease and claim not be payable for next 4 years. If no claim is lodged during next 4 years then, this disease will be deleted from the exclusion list from 5th year onwards.

Qus. Are Maternity/Pregnancy related expenses covered under Health Insurance plans?

In most of the policies it is not covered under individual/ family cover. Apollo Munich and Max Bupa cover this under certain conditions (Payable after certain number of years and also have limit on claim payable with limit for normal delivery and caesarean delivery. If you have Max Bupa’s insurance for Rs. 50 Lakhs then claim upto Rs. 1 Lakh is payable.

Qus. Is a medical checkup necessary before buying a policy?

Not for those who are below 45 Years.
In case of Oriental Happy Family Floater, this age is raised to 60 years.

Qus. What is coverage amount ?

Coverage amount is sum assured. This is the maximum amount which the insurance company will pay in the form of claim. The company may put sub-limits on the sum assured in the form of room rent etc. Please see the policy language carefully.

Qus. My wife and children are residing at Mysore while I am here in Bangalore. Can I cover all of us in one policy?

Yes this is possible. Policy is valid on all India basis and is also applicable if you are based in Bangalore and need hospitalization while traveling or want specialized treatment in another city may be Mumbai or Delhi.

Qus. Does health insurance cover diagnostic charges like X- ray, MRI or ultrasound?

If you are hospitalized, then charges for X- ray, MRI or ultrasound are payable provided these are required for the treatment for which you are admitted. If these tests are conducted within 30 days prior to Hospitalization and lead to diagnosis for which you are admitted for curative treatment then this is also payable. If any of these tests are conducted and are not relevant to the treatment then these are not payable.

Qus. What do you mean by Cashless Hospitalization?

The Insurance Company or the TPA (Third Party Administrator) working on behalf of Insurance Company gives instruction to the hospital to treat the insured person and do not collect the payment from the insured/patient – but to send the bills to them (Insurance Company or the TPA) for payment. This is what is called Cashless Hospitalization.

Qus. Is Health Insurance the same as Life Insurance?

No, health insurance and life insurance are two different types of insurance. In life insurance you get the maturity amount in case of death or maturity and in health insurance your hospitalization expenses get paid by the insurance company.

Qus. How much should you invest in health insurance?

You have to invest according to your requirements and the resources you have. You can invest by deciding about your budget for health insurance or if budget is not a constraint, you can invest by deciding about the sum assured and services required by you.

Qus. I am not satisfied with the company I currently have my health insurance with. How often can I switch companies?

It is not advisable to switch the insurance companies, frequently. You can do as many times as you wish.

Qus. What happens to the policy coverage after a claim is filed?

The coverage is reduced by the sum claimed by you. Total sum payable during a year is sum assured written on the policy.

Qus. What is the maximum number of claims allowed over a year?

There is no limit on number of claims allowed during the year.

Qus. What are the documents required for buying a health insurance?

It depends on company to company. Generally you need following documents:

  • Dully filled proposal form of the insurance company.
  • Medical examination papers if you are above certain age (generally 45 years – but can vary from company to company).
  • Photograph of the persons to be insured.
  • Photo ID proof of the proposer.
  • Cheque issued by the proposer.
Qus. In the event of claim being already made, If I want to renew my policy for the second year, do I have to pay premium again?

Yes, you will have to pay the premium every year as the policy is issued for one year (Similar to motor insurance). Some companies like ICICI Lombard even issue policy for 2 years.

Qus. Will the agent be helpful in settling of claims in future?

Yes, your agent will be helpful but he is getting 100% of his income from the insurance company and he may be getting .001 % of his income from you. If he has to make a choice, it is natural that he will favour Insurance company. You are the best person to decide whether to buy directly from the company or through an agent. Theoretically the agent is supposed to help you in claim settlement but time will tell when the claim is to be lodged. Be positive and buy it through agent but better buy through an Insurance Brokerage Firm as it offers wider choice and is large enough to protect your interests.

Qus. What are the minimum and maximum policy durations for Health Insurance?

Normally it is 1 year. Some companies offer 2 years also. Products offered by life insurance companies are of longer duration but payment is to be made every year.

Qus. Can I buy more than one Health Insurance policy?

Yes, you can buy more than one insurance policy but the claim should not be duplicated to two insurance companies. Under normal circumstances the claim amount will be shared by both insurance companies in the ratio of the sum insured. Let us say Company ‘A’ insured you for Rs. 2 lakhs and Company ‘B’ insured you for Rs. 3 lakhs, then the claim will be shared in the ratio of 2:3. In case you have gone in for a normal policy of Rs. 2 lakhs from Company A and Top-Up policy of Rs 3 lakhs from United, then in that case first Rs. 2 lakhs will paid by Company A and the claim above Rs. 2 lakhs will be paid by United. Top up Policy costs less than normal policy of Insurance Company. For right advice it is always better to consult an Insurance Brokerage Firm

Qus. Can I buy health insurance policy if I am not an Indian National but am living in India?

Yes, if you are a student studying in India or working on a valid work Visa then you can get the policy. But if you are a tourist coming to India for 3 weeks, it will not be worthwhile to buy this as 30 days cooling off period itself offsets the benefits which you are looking for. Medical tourism cases are definitely not covered in policy issued in India.

Qus. Who will receive the claim amount under health insurance if the policyholder dies during the time of treatment?

Nominee will receive the amount if the policyholder dies during the time of treatment.

Qus. Can I seek treatment at home and be reimbursed for it under health insurance?

It can be possible in exceptional cases only when there is epidemic and no beds are available in hospitals. You must take approval from Insurance Company while undergoing treatment – otherwise your claim will be rejected.

Qus. I might be laid off soon. Should I see my doctor before I lose my insurance?

No purpose will be served by seeing your doctor. You should consult an insurance brokerage firm and buy a health insurance policy which should be in place 30 days before your last day in your company. This protects your interests as on the day you leave the present employer –on the same day cooling off period of your new policy will be over.

Qus. I Am Unable To Work Due To Disability. What Are My Options For Health Coverage?

It depends on the disability. We suggest that you should buy a health insurance policy. Suppose you are disabled due to poor eyesight, you may not be able to work but you may fall ill and need hospitalization. Insurance company will put eye disease/ ailment as pre existing disease and it may not be payable –but there can be hundreds of other ailment and accidental happenings, which get covered.

Qus. Who is a Third Party Administrator ?

TPA is an abbreviation for Third Party Administrator. These companies are BPO of insurance companies and are responsible for coordinating all aspects of claims arising due to health insurance policies.
These companies are licensed by IRDA (Insurance Regulatory & Development Authority) and are having:

  • Telecom facility generally with phone number starting with 1600 (toll free no.)
  • Computer network having details of all policies holders.
  • Medical specialists, for assessing need for hospitalization treatment being given in the hospital and for passing of the claim bills.

The role of TPA is to coordinate with hospitals with respect to treatment and also pass the bills on behalf of the insurance companies. The actual payment is made by the insurance company. As far as the legal contract is concerned, it is between the insurance company and the person insured.
The individual insured will get an ID card issued by the TPA. This ID Card is useful and needed at the time of hospitalization.

Qus. Are naturopathy and homeopathy treatments covered under a health policy ?

In all policies naturopathy is not covered. However Homeopathy is now being covered by some insurance companies provided treatment is taken in a Homeopathic Hospital, which is empanelled with the insurance company. Star Health permits use of Homeopathic medicines during post hospitalization period.

We foresee more and more insurance companies will start covering naturopathy and homeopathy treatments in future as more and more organized hospitals covering naturopathy and homeopathy will come up.

Qus. Why should I buy a critical illness cover?

Critical Illness cover is for specific diseases like cardiac/cancer etc. Generally list comprises of 8 to 12 but in a specific company this may be as high as 35.On happening of the diseases lump sum payment may be made – giving you the option of choosing the treatment. For example you may like to have naturopathy or yoga path as guided by Baba Ram Dev. Generally this policy is given by Life Insurance Companies as a stand alone policy or as an additional rider in your life insurance policy (against some additional premium).Even now you can add it to your existing policy in case it does not have this rider.

Qus. Does my Individual Insurance Policy cover mental health benefits (treatment for mental diseases)?

No. it does not cover treatment for mental diseases. We do hope that in near future insurance companies will come out with innovative products which will cover this.

Qus. Will my health insurance coverage Clinical Trials?

We feel that if treatment is

  1. Part of hospitalization in a reputed hospital like AIIMS, capable of conducting clinical trials under controlled conditions.
  2. Under supervision of a reputed doctor
  3. Clinical trials are approved by Medical Council (Ministry of Health)

Then it will be payable. If it does not fulfill these conditions then you may have difficulty in getting it paid as the issue is around treatment as well as the price of the medicine.

Qus. What’s the Difference Between Co-pays and Co-insurance?

Copayment is that what % you will pay and the balance is to be paid by the insurance company.
Coinsurance is not applicable to individual’s health insurance policy. It is applicable to insurance of large plan with premium say Rs 20 lakhs and above where 2 or more insurance companies share the premium and the risk. The insurance policy is issued by Insurance Company having maximum share, then it collects the premium and gives cheque to other insurance companies. At the time of claim, they pay the claim and collect the amount from the insurance companies.

Qus. Which medical tests does an adult above 45 years needs to go through?

It depends on the company. Generally it comprises of

  • Blood Tests
  • Urine Tests
  • ECG

As the age progresses, the list increases. For 60/70 years, the list will comprise of extra tests.

Qus. I own a pet and my vet bills are sky-high. Is there such a thing as health insurance for animals?

It depends on pet. But definitely it is not part of Health Insurance policy which is for human beings only. Cow, buffalo are covered under Cattle Insurance. Please describe the pet so that we can answer your question more specifically.

Qus. Who is entitled to an overseas mediclaim policy?

It can be purchased by any one who is planning to undertake overseas trip (foreign trip) by road/sea/air. Your normal policy is valid only in India and is not valid outside India.

Qus. Should I pay my premiums through the agent?

If he is ready to provide you the service – yes. It is your duty that cheques should reach the insurance company well in time. Not picking up of the cheques by the agent is no excuse. If your cheque has not reached the insurance company on time, your policy may have a break and you may lose the benefits.

Qus. Is there any disadvantage if we buy health insurance as part of group insurance (for e.g linked to account holders of banks) if the right cover amount is taken.

There is no disadvantage. You should keep in mind that if you close your account with that bank then you are out of that group and hence the benefit of policy is also gone.

Qus. I already have a health insurance policy. Should I still buy a life insurance policy with the riders?

Health Insurance Policy covers your hospitalization needs. Life insurance covers your retirement needs. Adding of critical illness rider will take care of incidence of you getting critical illness like cancer.
Every product is different and fulfills different needs. Study it and make a decision.

Qus. Hi! Are the new clinical and pathological tests, not available in India and done abroad covered under the mediclaim rules of the country? If no, are efforts being made to do?

You are only permitted by some insurance companies to take e-opinion. Your suggestion is very good and we feel Insurance companies will start offering the same. If Textile industry is permitted to get flammability tests done on garments in Hong Kong then why Insurance companies should not permit clinical and pathological tests (not available in India), which are to be conducted in foreign country.

Qus. Is there a mediclaim policy which is truly 100 percent cashless?

Yes, nearly 100% policies are cashless. You will appreciate that it can be cashless in case of planned hospitalization as well. Supposing you are involved in an accident and are taken to the hospital – you may have to pay advance to the hospital. In few hours time coordination can be done and the hospital may have the message from Insurance Company for cashless hospitalization.

Qus. I am having Health First policy of Tata AIG so I am covered for Mediclaim/hospitalization. Therefore I do not need any other policy?

Health First is a product of Tata AIG Life. You are aware of that a Non Life Insurance Company or a Health Insurance Company (like Star) issues Mediclaim policy. Health First covers the following 12 critical illnesses only :

  • Cancer
  • Stroke
  • First Heart Attack
  • Coronary Bypass Surgery
  • Chronic Renal Failure
  • Major Organ Transplant
  • Aorta Surgery
  • Alzheimer’s Disease
  • Benign Brain Tumor
  • Heart Valve Surgery Paralysis
  • Parkinson’s Disease
  • Total Blindness

It will not cover hospitalization due to other diseases or accident. Therefore having of Mediclaim policy from a non life insurance company in addition to Health First will be in your interest.

Qus. Will like to have insurance cover of Rs12,00,000. Which insurance company will issue it?

Most of the insurance companies issue policy for Rs. 5,00,000 only. Cholamandalam issues Mediclaim policy of Rs. 10,00,000 subject to certain earning norms being fulfilled. In view of the medication costs/treatment associated with certain ailments various Insurance Companies are considering to increase the sum assured to Rs 10,00,000. In the coming months suitable notifications are expected from IRDA as well as insurance companies. You cannot be covered for Rs. 12,00,000.

Qus. Someone had mediclaim policy and he had to pay nothing for treatment in a hospital. Which company provides this good service?

TPA’s (Third Party administrator) are approved by IRDA. They provide service with respect to coordination of treatment in hospitals/settlement of bills on behalf of Insurance Companies. Every Insurance co offers this cashless settlement facility. Even if TPA settles the bill with hospital you may have to submit your bill to TPA with respect to bill for 30 days prior to hospitalization and 60 days post hospitalization. There is a list of TPA’s given in this book. In your insurance policy the name of the TPA with whom you should coordinate is given. The name is also given on the ID card issued by theTPA to you. Toll free number of TPA is given on ID Card and you can dial it from any part of the country on free of cost basis.

Qus. Is there any difference between TPA’s?

All TPA’s are approved by IRDA. Some of them charge 6% of premium as the service charge and some of them charge 10% of premium as the service charge. This cost is ultimately being paid by the insured only. It is included in the premium being charged from insured.

Qus. Can we say an insurance company will be attached to one TPA only?

Not necessary. An insurance co. may be using more than one TPA.; Sometimes they use one TPA for individuals/ families and another one for Group Mediclaim policyholders.

Qus. We have group insurance policy for our organization. Do we have choice of selecting one of 4 TPS empanelled with Insurance Companies?

Insurance companies will by to push then favourble TPA. You have the right to invite various TPA’s, let them make presentation, reply to your queries and then select a TPA. Infact as an aware consumer you should insist for this.

Qus. At present I am covered under group Mediclaim policy, which my employer organization has provided. When I retire at the age of 60 then I will take a policy in my name. Please comment?

Theoretically you can take the Mediclaim policy when you are 60.In practice it may not be so. Most of the Insurance Companies are not underwriting policies for those who are above 50 years. ICICI Lombard is the only one but the policy you can take here is having the maximum limit of Rs. 2,00,000 only. It means even if you are covered for Rs. 3,00,000 under the group policy of your employer you may have to agree for sum assured of Rs. 2,00,000 at a time when due to age your need may be higher.
Royal Sundaram can insure you at this stage, provided your child is the proposer and also takes the same sum assured. It means if wish to get insured for Rs. 3,00,000 then your son, his wife should also be covered for Rs. 3,00,000 each. Royal Sundaram has maximum limit of Rs 3,00,000. Let us take an example.
At the age of 49 years you take policy of Rs. 5,00,000 then you will be paying Rs. 6500/year. Till the age of 70 you will pay Rs. 6500 x 21= Rs. 132000.If at the age of 60 years you tak ICICI Lombard policy then from 60 to 70 years for coverag Rs. 2,00,000 you will pay Rs. 14000×10 = Rs. 1,40,000. This shows that it is better to take a policy on your own account in addition to your employer scheme.

Qus. A patient is treated at home for fever. Are the fever treatment bills payable by the Insurance Company?

If family doctor or consultant doctor does the treatment of the fever at home then it is not to be paid by the Insurance Company.If due to critical state of the patient or due to epidemic the patient is admitted in a hospital then the claim is payable provided 24 hours hospitalization condition is met.

Qus. Is the maternity expense/hospital bill payable by the Insurance Company?

It is subject to the policy condition.In most of the individual/ family policies it is not included. In some of the group Mediclaim policies it is covered and is clearly mentioned. Generally where payable this specific claim is payable in second year of the policy. In exceptional cases In-Group Mediclaim it is covered from the beginning as the corporate buyer has negotiated the policy by paying the suitable incremental premium for availing the benefit. You should read the condition in the policy document carefully.

Qus. What is day surgery? Is it payable?

Day Surgery is the surgery where patient need not spend the night in hospital and is discharged after few hours. List of the day surgeries covered under Mediclaim policy of Cholamandalam is appearing in this book. They have the most elaborate list. Other Insurance Co’s have shorter list and it appears in the policy document.

Qus. My credit card gives Mediclaim policy? Should I go for it?

Mediclaim policy is purchased by the credit card company. It is infact a group Mediclaim policy with certain additions/ deletions which are agreed with Insurance Company.

In the cases of Royal Sundram policy being sold by SBI credit card you get No claim bonus of 5%. No claim bonus which you get is 15% if you go for direct policy from Royal Sundaram.

Qus. Is it true that PSU’s offer the lowest rates for Mediclaim?

For a specific age one Insurance company may be lower and for some other age another one may be lower. The best way is that you calculate the premium payable on the basis of all family members. From the following comparison you will notice that Royal Sundaram is economical for this family versus other companies.

Comparison of Different Insurance Companies rates for Mediclaim – each member covered for Rs. 1,00,000

Inclusive of Service tax Rs.
Age Royal Sundaram Bajaj Allianz PSU’s
52 2731 3135 2289
47 2275 2090 2289
22 958 1408 1470
16 958 1408 1470
Total 6922 8041 7518
Less Family discount 692 804 752
Premium Payable 6230 7957 6766

It is generally noticed that premium variation is in the range of 4% with the exception of ICICI Lombard where the premium for the product offering floater benefit is higher. This is because this product is presented as a premium product based on Better service,

  • Medical examination cost of all that are to be insured is to be done at nominated clinic at company cost. Those who are going in for this product need not go in for routine medical tests at their own cost.
Qus. TPA & Insurance company have disallowed my claim. What is the option available for me?

You can take up the matter with head office of the insurance company. If not satisfied with their decision you can take up the matter with Insurance Ombudsmen in your area. List is given in this book. If not satisfied with their decision then you can lodge case with consumer forum at district level.

Qus. Underwent surgery for a retinal tear and was in hospital only for a couple of hours. Can my claim be rejected on the ground that i was not hospitalised for a minimum of 24 hours?

No, your claim cannot be rejected on this ground since the “24 hours” condition does not apply to certain surgical procedures – those that don’t require extended hospitalisation.

Qus. I have no medical policy and I suffer from hypertension. Will I get a health insurance cover?

Definitely you can get a health insurance cover, but hypertension would be treated as a pre-existing disease and it will get covered only after a period of 4 years. Diseases which occur as a consequence of hypertension will not be covered during first 4 years.
However you get an option in the policy issued by New India and can get it covered from 2nd year onwards by paying 20% additional premium. By paying the additional premium you will get 50% coverage in the 3rd year, 75% coverage in the 4th year and 100% coverage from 5th year onwards.

Qus. Please suggest a policy that covers regular check-ups and OPD treatments, including dental.

Health insurance policies issued by non-life insurers do not cover OPD and dental expenses. However, life insurers such as the Life Insurance Corp. of India (LIC) and ICICI Prudential have come out with health insurance plans that allow the insured to accumulate a health fund. The premium paid for these policies has two portions. One portion goes towards the hospitalization cover, while the other goes into a savings account. This account accumulates money over the years. The insured person can withdraw money from this fund to meet with OPD and dental expenses.
You have two options ICICI Lombard’s “Health Advantage Plus” and Apollo Munich’s “Maxima” Health Insurance plan.
ICICI Lombard’s Health Advantage Plus covers OPD expenses from the first day of the policy. The OPD cover may vary from Rs. 2,000 to Rs. 10,000 depending on the plan opted and your age. You can claim OPD charges only once during the policy term, which means you will have to collect all the bills and get the reimbursements as and when the limit is reached.
The Apollo Munich’s Maxima covers, cash- less OPD expenses across trusted network of pharmacies for pharmacy bills, diagnostic centers for diagnostic tests and annual health check-up, dental and optical care centers for contact lenses, spectacles and dental treatments along with consultation with family doctors. In Maxima OPD cover is sub-divided. The maximum benefit allowable for 1 adult is Rs. 8,500.
In addition, both the policies do not allow, an insured person to claim OPD cost within 90 days of commencement of the policy.

Qus. We are getting the insurance cover from my Credit card at a heavy discount then why I should go directly to Insurance Co.?

The product offered under credit card scheme has different risks covered also carries administrator cost at rate of Rs. 175 to Rs. 250 per person.So for a family of four it adds up to approximately Rs. 1000.

The analysis reveals that going for the policy from the Insurance company is more beneficial in the long run as cost in Rs/Lakhs in the fourth year at Rs.807 is lower for Royal Sundaram insurance rather than buying the same through S.B.I. card.

Let us go into an in depth study;

In September 2004, the following study was made on the basis of leaflet being circulated by S.B.I. card to its card holders.

Sum Assured Is Rs. 1,00,000 for each member
Name Age As per SBI Card Royal Sundaram Premium for Royal Sundaram (Rupees) Premium for Cholamandalam
Mr. Lall 42 1230 1485 1560
Alka 36 1230 1485 1560
Suman 6 1200 934 1208
3660 3904 4328
Discount 915 390 433
Administration on Fee175 * 3 525 0 0
Total 3270 3514 3895
Benefit No Claim No Claim No Claim
Bonus is 5% Bonus is 15% Bonus is 10%
After 3 yrs 115000/- 145000/- 130000/-
Sum Assured Per Person Per Person Per Person
Cost Rs. /Lakh 947 807 998

Generally people switch over the credit card in 2 years time depending on the:

  • Cost/Year
  • Service not being satisfactory
  • Attractive incentive offer being made

You may not like to stick to a credit card for a long time only because health Insurance was purchased through credit card. If you are not the credit card holder then you can not be a member of the group so you can not be-covered under the policy. You Will not receive renewal notice also and changes are you will be uninsured.

What emerges out is that

Read the details in any such offer carefully and then only decide. Do not be impressed with 40% discount offer as it is shown in this leaflet.

Qus. I want to take health Insurance policy for my sister who has paralysis. Which company should I approach? What is the process involved?

You can take Oriental’s Happy Family Floater policy in which you would be able to cover your daughter along with you and your wife. You will have to take individual policy for your son as his age is above 25 years and is not to be considered as your dependent. You can take Oriental’s Individual policy for your son. The premium for Rs. 5 lakh of cover would sum up to Rs. 18,670. You will have to bear co-payment of 10% when lodging a claim.
If you increase the sum assured to Rs. 6 lakhs, there is no co-payment. The premium for Rs. 6 lakhs cover will sum up to Rs. 23,630.

Qus. I want to take health Insurance policy for my sister who has paralysis. Which company should I approach? What is the process involved?

Name Age Rs.5 Lakh Rs.6 Lakh
    (Oriental) (Oriental)
    (Family Floater Silver) (Family Floater Gold)
Shri B.N. Shukla 55 10400 14210
Mrs. Shakuntala Shukla 52 2080 2840
Ankita Shukla (Daughter) 25 1040 1430

Name Age Rs.5 Lakh Rs.5 Lakh
    (Oriental) (Oriental)
    (Individual) (Individual)
Gaurav Shukla (Son) 28 5150 5150
Total   18670 23630
Qus. What are the eligibility criteria for purchasing International Student Health Insurance?

You should be a student of a school/ college/ university in the foreign country and have a valid student visa.

Qus. Are dependents of students of overseas student Health Insurance also eligible for coverage?

They are eligible but they do not get student Health Insurance Policy. They get normal Overseas Travel Policy.

Qus. May I purchase Student insurance if I am already studying outside my home country?

Yes- you can purchase. But see requirement of your educational institution –what sum assured they are looking for.

Qus. What is Domestic Travel Insurance?

This is travel insurance –when you are traveling within India.

Qus. Am I still covered by Domestic Travel Insurance if I catch a connecting flight to a different destination?

Yes- it is for number of days and it covers all modes of public transport – road, rail & air. It also covers accidents/ illness/ hospitalization etc.

Qus. What can I do if I encounter an accident while covered under Domestic Travel Insurance?

Get treated and it will be paid by the insurance company.

Qus. Ways health insurance companies can mess with you?

They are in business of providing service – why they should mess with you. You as a responsible customer should follow the rules/ procedure for lodging claim. It is a good idea to refer to policy document, read it thoroughly and avoid hassles.

Qus. My insurance company failed to authorized coverage and treatment. Is there anything I can do?

You should analyze the reason why they have not authorized payment. Refer to policy document as well as medical document. If it is not covered in policy then you can not do anything. If it is covered under the policy, you have the following options:

1. Take up the matter with the branch office.
2. Lodge grievance with the Head Office of the Insurance Company.
3. Lodge your grievance on website of Insurance Foundation of India.
4. Go to Insurance Ombudsman.
5. Go to consumer forum.

Qus. How does the health care ombudsman role work?

There is no post of health care ombudsman. It is Insurance Ombudsman and it is at state level. Sometimes an Insurance Ombudsman may be covering 2 or more than 2 states also. He also covers all cases of Health Insurance.

Qus. What is a network?

This term is used whether the hospital is empanelled with insurance company/ TPA or not. If it is then it is called as network hospital of the insurance company.

Qus. How do I waive student health insurance?

If you are a student in a foreign educational institution then you can not escape yourself from this responsibility. You must have the policy. It is in your interest.

Qus. Can I enroll in both my own employer’s plan and my spouse’s plan? Is it worth the extra cost I would have to pay in premiums? What about our dependent children?

Yes- you can. The same is applicable for your dependent children. Decision making can be done on knowing facts & figures. Seeing the health case costs you may consider going in for both.

Qus. What types of expenditures are commonly excluded under health insurance policy?

Expenditure commonly excluded is:

● Costs which are not associated with treatments
● Diagnostic Tests not associated with treatments
● Medicines which you might be taking every day but are not part of this treatment.

Qus. Is there a minimum annual income requirement under Critical Illness insurance?

No. but if you are planning to go in for a very high sum assured –then Insurance company many ask for the same.

Qus. What type of hospitalization expenses are not covered by Mediclaim?

You have to refer to exclusion lists (1 year/2 years/4 years/permanent exclusion. Any thing not covered in these is supposed to be covered.

Qus. Is there a minimum time limit for stay within the hospital under Mediclaim?

Yes – 24 hours is the limit. This is waived off in case of Day surgery for which every company has its own list. One insurance company has list of 147 day surgeries.

Qus. What happens when the limit of insurance is exhausted under Mediclaim?

Nothing is payable beyond this limit so you have to pay for treatment out of your own pocket. You will have to wait for year to end, pay renewal premium – again you start with same limit as mentioned in new policy.

Qus. Is the insured value based on my income?

Not in case of health insurance. It is based on what you have the capacity to pay.

Qus. I made a mistake in entering my data while purchasing the insurance, what should I do?

Inform the insurance company, get it charged/ corrected. It is in your interest.

Qus. Do I receive a discount if I buy the policy for my entire family together?

Yes if it is normal policy with sum mentioned against the name of every family member – then you are eligible for discount of 10% for more than 2 persons. But in case you go for family floater then premium itself will be lower-may lower by 25%. No discount will be mentioned or given to you separately.

Qus. If a claim has been made for a particular ailment; does it become a pre-existing disease for the next policy term?

No, if you continue with the same insurance company. But if you go to a new company then it will be treated as a preexisting one and it becomes non payable.

Qus. My son is studying in the USA. I want to take health insurance for him. Will any one guide me which Company in India offers the best policy for an Indian student in the USA?

Yes – you can contact an insurance brokerage firm and they will give you good choice. You can contact us at Ria (9810090853 or 01141324957)

Qus. Is it possible to transfer insurance from one company to another and yet get the No claim/history of claims.

Generally- yes. you can get no claim bonus if you can prove that you did not lodge any claim for last few years.

Qus. I have an impression that the health insurance sector is not regulated in India. If you have a policy and take a claim then next time the insurance companies denies the extension of the policy or minimum they do is to charge very hefty premium. In that case what is the fun in taking medical insurance?

IRDA is doing a wonderful job in regulating insurance industry of this country. You might have had bad experience with a company. Generally it does not happen. But if you lodge claims in 2 successive years- then you will face difficulty.

Qus. What are the benefits of floater plan?

Family floater policy is giving you better rates. If you have a normal policy then every member is eligible for sum mentioned against his name. In family floater sum is for the family so any one/ some/ all family members can lodge claim.

Qus. What should I keep in mind before obtaining services from TPA?

Keep policy number/ ID Card No. handy. Prescription of doctor advising hospitalization, who will conduct procedure/ surgery in hospital, what is the treatment to be given, what is estimated cost, Expected date of admission into hospital and for no of days you will be in hospital. TPA will ask these questions and will ask you to submit/ fax these documents.

Qus. What happens in the event of an injury or illness that demands immediate medical attention?

Life is important. Injured/ patient should be taken to doctor/ nearest nursing home/ hospital and emergency treatment should be provided. At appropriate time if necessary the patient can be moved to an empanelled hospital in consultation with the insurance company/TPA.

Qus. How do I purchase the insurance? When does the insurance take effect?

You can purchase health insurance from Insurance Company or through insurance intermediary–i.e. agent/ adviser/ Insurance Brokerage Firm. It is better to buy through Insurance intermediary as you get support in the event of lodging claim.

Qus. Should I purchase a combined policy for my parents or separate individual policies as both my parents are visiting me?

Yes – it is better to have combined policy. You can also include their names in family floater policy. You will same money.

Qus. What ate the Documents Required by TPA for giving approval for cashless settlement?

1. Name of patient, policy no, Insurance Company.
2. Prescription of Doctor advising admission to hospital/ Details needed are.
(a)- Disease to be cured
(b)- Treatment/ surgery suggested
(c)- Who will treat/ perform surgery/ date of admission into which hospital
(d)- Expected duration (no of days) in hospital
(e)- Estimated cost for Treatmen
These documents will be needed by TPA and can be.
1. Person
2. Fax
3. Email
3. Medical officer of TPA will see the docs, talk to Hospital/ doctors if required and give on to hospital to treat the patient.
4. Collect authorization from TPA to show to hospital so that their do not ask for payment.

Qus. My father recently crossed 60 and he is diabetic. I want to buy health insurance medicliam for him. Please suggest some good plans and their benefits.

You have 2 options

Option 1. Get policy from any insurance company with exclusion of diabetes for 4 years.
Exceptions are- L + T where it will be covered after 2 years Bajaj Allianz Silver Health- where it will be covered after 1 year

Option 2. Get policy from one of the following companies.
(a) Star Health- Diabetic Care: You will have to pay 30% of the claim amount.

Qus. I delivered a premature child five months ago. Can I buy a health policy for him now?

As child is more than 90 days old yes, you can get the name added to your Health Insurance policy by paying premium for remaining period of the policy. If you would have Max Bupa policy and maternity claim was also paid by them then the name of the child would have been added immediately and without any additional payment.

Qus. My father and I are going to visit the US. Our travel insurance covers medical expenses too but it is from a company in India. If something were to happen to us in the US, how would we invoke the policy? Do Indian firms have offices in countries where they provide a cover?

Indian Insurance Companies have arrangements with companies in US as well as in other countries. You should not worry- you will get service everywhere in the world. Keep your policy handy during travel as it has helpline phone numbers. When you call helpline number you will need the policy number details to proceed further.

Qus. I bought a car in 2009. Now my car insurance renewal is due. My agent says that the insured declared value (IDV) of my car has not changed since last year. He is not able to explain what it is. Can you please explain what IDV is and how is it calculated. What impact will it have on my policy?

The relevance of IDV is realized in the event of total loss/ theft of the car. Various surveyors/ insurance companies come out with IDV list for every model/ make. Its IDV valve as mentioned by you should change – it should go down. By saying that value has not gone down may be that agent is trying to make some extra money. You may send details to Ria Insurance Brokers Pvt. Ltd. and they will tell you what is the correct IDV for you car.

Qus. I recently brought a 20-year-old independent house. Considering the age of building, the insurance company I approached has refused to insure my house. Can insurance companies do so? What should I do?

Insurance company should not refuse insurance of old building unless and until it is so old that it may collapse – anytime due to heavy rains/ floods or even minor earthquake. You can approach another insurance company and they will most probably insure it.

Qus. My motor insurance is due for renewal. My car is now almost eight years old and I am planning to sell it. Will there be any problem while selling a car if there is no insurance?

You must have valid 3rd party insurance. Otherwise there can be difficulty. If I am the buyer then I will not buy any car without 3rd party insurance because if it was involved in any accident in the past then I will be put to difficulty.

Qus. My uncle, who is 40 years old, recently went through an open heart CABG operation. We had assumed that his public health insurance policy would cover the entire cost. We were informed at the last minute that only hospitalization cost would be covered with some conditions. Is there a plan that covers all the cost involved in such a complex procedure?

Yes- large numbers of products are available which will cover the cost involved in such a complex procedure. Your uncle will not be covered for this disease/ ailment under the new policies as now CABG is a preexisting disease. It is always better to buy right health insurance when you are healthy. It is not possible to buy right health insurance when you have a disease/ ailment especially like CABG. Your uncle has to be prepared for spending a lot out of own pocket.

Qus. I have a health cover of Rs 3 lakh from Star Health. I want a top-up policy Rs 5 lakh. Please suggest some good options?

You have choice of United India Vs Star Vs Bajaj Allianz. This is subject to Star policy being in place for many years and that too without any claims.

Qus. I have heard that deafness is genetic and many private health insurance companies don’t cover children for several critical illnesses. I would like to know if there is a health plan that can provide medical relief to my child to cover doctor’s check-up expenses etc. Also is there a critical illness plan which can cover deafness if ever my child was to face it?

Children born with diseases are not covered. Policy is issued to a new born baby when he/she is 90 days old.

No insurance company will cover you child. Critical illness plan does not cover deafness. Under personal accident policy – deafness of 1 ear or 2 ears (due to accident) can be covered and under this the insured gets one time lump sum payment.