Financial PlanningInsurance

5 Health insurance plans for 2018

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Vipul is a 25 year Software Engineer working with a leading MNC in Pune. Last month, his mother had to be admitted to the hospital due to a heart attack. The 6 day hospitalisation and medical treatment bill that Vipul paid was of Rs. 4 lakh. He had to pay this amount out of his savings as he did not have a health insurance plan for his family. Vipul had not realised the importance of investing in a health plan. Hospital bill payment left a huge dent in his savings. Like Vipul, there are many individuals who fail to realise the importance of investing in a health insurance plan.

The reality of life is that the cost of medical treatment and hospitalisation is rising day by day. Medical emergencies can arise at any time either for you or for a loved one in the family. If you or any family member has to be hospitalised, due to some serious health problem, even for a couple of days, it can leave a huge dent on your savings. Hence it is best to invest in a health plan at the earliest.

There are so many health insurance plans in the market today, which makes it a little difficult for an individual to select a health insurance plan suitable for himself/herself and his/her family. In this article we will discuss about a few important aspects that you should study in a health plan before deciding to purchase it. We have also discussed the important features of some health insurance plans available in the market. We will try to help you in shortlisting a health insurance plan that suits your need.

Comparison of health insurance plans
In the below table we have presented a comparison some health insurance plans.
For premium calculation we have taken the following data:
Plan type: Family floater
Number of adults covered: 2
Number of children covered: 0
Age of the senior most member: 25 years
Sum assured: Rs. 10 lakh
Plan duration: 1 year

Company name Max Bupa Apollo Munich HDFC ERGO ICICI Lombard Aditya Birla
Incurred Claim Ratio 51.96 54.99 50.76 90.22 110.68
Plan name Heartbeat Family First Health  Insurance  (Silver variant) Easy Health –  Family Health Insurance Plan (Standard variant) Health Suraksha (Silver variant) Complete Health Insurance or iHealth (Option C variant) Activ Health Essential Plan (Platinum variant)
Minimum and maximum sum assured (SA) Min SA: Rs. 3 lakh

Max: Rs. 15 lakh

Min SA: Rs. 2 lakh

Max SA: Rs. 15 lakh

Min SA: Rs 3 lakhs

Max SA: Rs 10 lakhs

Min SA: Rs 2 lakhs

Max SA: Rs 10 lakhs

Min SA: Rs. 50,000

Max SA:  Rs. 10 Lakhs

Premium Rs. 12,751 Rs. 12,922 Rs. 14,069 Rs. 7,637 Rs. 12,326
Co-pay / Sub-limit Co-pay optional: 0% or 10% or 20%

Room rent capped at Rs. 3000 per day or shared room

No co-pay

No sub-limit on room rent

No sub-limit on room rent

 

Sub limits can be optionally availed for SA up to Rs. 7 lakhs and below Mandatory co-payment of 20%
Reward/Bonus 10% increase on base sum assured every year, irrespective of claim status till 50% of base sum assured Cumulative bonus of 10% of SA for every claim-free year Cumulative bonus of 5% of SA for claim free year, subject to maximum of 50% increase of sum assured Cumulative  bonus of 10% on SA for claim free year Cumulative bonus of 10% on SA for claim free year, maximum up to 100% of sum assured
Maternity expenses waiting period 2 years Not covered Not covered Not covered 4 years, if optional cover availed
Maternity coverage Maternity benefits for up to 2 pregnancies or terminations.

Covered up to Rs. 35,000 per policy year

Vaccinations of new born baby for 1st year

NA NA NA Available as optional cover on payment of additional premium
Waiting period for pre-existing conditions 4 years 3 years 4 years 2  years if SA is Rs. 3 lakh or more, else 4 years 4 years
Free medical check-up Once in 2 years Once at the end of block of every continuous 4 claim free years.

Up to 1% of SA

Reimbursement of 1% of sum assured or Rs. 5000, whichever is less, after 4 continuous claim free years Free medical check-up available once every year, subject to maximum 2 members in a family Once in a policy year
AYUSH treatment Covered up to sum assured Covered up to Rs. 20,000 Covered Covered Not covered

Wherever multiple variants of the plan are available, we have considered the basic variant so that we can compare similar features of plans across companies.

The incurred claim ratio (ICR) is for 2016-17 as taken from IRDAI annual report. The ICR is overall for standalone health insurance companies like Apollo Munich, Aditya Birla Health Insurance and Max Bupa and for the overall health segment for companies like ICICI Lombard and HDFC Ergo. The ICR is not for the specific health insurance plan.

Detailed analysis of health insurance plans of various companies

Health insurance plan 1: Max Bupa Heartbeat Family First Health Insurance

The Heartbeat plan is available as an individual plan as well as a family cover plan. The family cover plan is further available in two options:

  1. Heartbeat Family Floater: This option is suitable for nuclear families wherein husband, wife and children can be covered.
  2. Heartbeat Family First: This option is suitable for joint families and can cover up to 19 relationships in the family.

Heartbeat Family First: In this article we will focus on Heartbeat Family First as it has wider scope of coverage. It caters to the health insurance needs of all the family members. It is offered in three variants: Silver, Gold and Platinum. Under the Silver variant, the sum assured (SA) starts from Rs. 3 lakh and benefits offered are limited. Under the Platinum variant, the SA starts from Rs. 15 lakh and offers wide range of benefits. The benefits offered under the Platinum variant even cover the cost of treatment abroad for certain critical illnesses.

In the below table we have presented a comparison between all three variants of Max Bupa Heartbeat Family First Plan.

Note: For premium calculation, we have taken Sum assured: Rs. 15 lakh, Number of adults covered: 2, Age of the senior most member: 25 years, No of children covered: 0, Policy term: 1 year

Max Bupa Heartbeat Family First Health Insurance Silver Gold Platinum
Min and Max SA Min SA: Rs. 3 lakh

Max SA: Rs. 15 lakh

Min SA: Rs. 3 lakh

Max SA: Rs. 50 lakh

Min SA: Rs. 15 lakh

Max SA: Rs. 50 lakh

Premium Rs. 13,065 Rs. 19,718 Rs. 63,305
Sub limit/ Co pay Co-pay optional: 0% or 10% or 20%

Room rent capped at Rs. 3000 per day or shared room

Co-pay option of 0% or 10% or 20%

Room rent covered up to sum assured (except for suite or above room category)

Co-pay option of 0% or 10% or 20%

Room rent covered up to sum assured (except for suite or above room category)

Reward/Bonus 10% increase on base sum assured every year, irrespective of claim status till 50% of base sum assured 10% increase on base sum assured every year, irrespective of claim status till 100% of base sum assured 10% increase on base sum assured every year, irrespective of claim status till 100% of base sum assured
Maternity benefits Covered up to Rs. 35,000 per policy year Covered up to Rs. 50,000 per policy year Covered up to Rs. 1,00,000 per policy year
Maternity coverage  waiting period 2 years 2 years 2 years
Waiting period pre-existing conditions 48 months 24 months 24  months
Free medical check-up Once in 2 years

Tests as mentioned in policy document

Annual test covered up to Rs. 2500 per insured person Annual test covered up to Rs. 5000 per insured person
AYUSH treatment Covered up to sum assured Covered up to sum assured Covered up to sum assured
OPD treatment and diagnostic services Not covered Not covered Covered up to Rs. 35,000
Child care benefits Not covered Not covered Vaccinations up to 12 years covered up to sum assured

Following are the common points for all the 3 variants of the plan:

  • Pre-hospitalisation expenses are covered for 60 days immediately before hospitalisation
  • Post-hospitalisation expenses are covered for 90 days immediately after discharge from hospital
  • Maternity benefits for up to 2 pregnancies or terminations. New born baby is covered up to the end of the policy year. Vaccinations are covered for the first year.
  • Day care procedures (which do not require 24 hours hospitalisation) are covered
  • 30 days initial waiting period for any treatment, unless it is a result of an accident
  • 2 years waiting period: There is no specific waiting period for people aged 45 years and below. For persons above 45 years of age, some conditions will be subject to a waiting period of 24 months.
  • Life time renewability of all 3 plan variants

Health insurance plan 2: Apollo Munich Easy Health (Family Health Insurance Plan)

This is the family floater variant. To cater to different types of customer, the company offers 3 variants under this plan: Standard, Exclusive and Premium. Standard variant of the plan is the basic plan with the lowest SA and premium variant is a more comprehensive and high end product.

In the below table we have presented a comparison between the benefits offered under different variants. For the premium calculation, we have taken details as follows: Number of adults covered: 2, Age of the senior most member: 25 years, Number of children covered: 0, Sum assured: Rs. 15 lakh and Policy term:  1 year

Plan Variant Standard Exclusive Premium
Minimum and maximum sum assured (SA) Min SA: Rs. 2 lakh

Max SA: Rs. 15 lakh

Min SA: Rs. 3 lakh

Max SA: Rs. 50 lakh

Min SA: Rs. 4 lakhs

Max SA: Rs. 50 lakhs

Premium  (inclusive of tax) Rs. 15,490 Rs. 18,880 Rs. 22,760
Waiting period First 30 days of cover First 30 days of cover First 30 days of cover
Reward/Bonus Cumulative bonus of 10% of SA for each claim free year Cumulative bonus of 10% of SA for each claim free year Cumulative bonus of 10% of SA for each claim free year
Maternity expenses Not covered Covered Covered
Maternity benefits  waiting period NA 4 years for SA up to Rs. 10 lakhs

3 years for SA more than Rs. 10 lakhs

4 years for SA up to Rs. 10 lakhs

3 years for SA more than Rs. 10 lakhs

Maternity expenses coverage NA Normal delivery: Rs. 15,000 to Rs. 30,000 depending on SA

Caesarean delivery: Rs. 25,000 to Rs. 50,000

Normal delivery: Rs. 15,000 to Rs. 30,000 depending on SA

Caesarean delivery: Rs. 25,000 to Rs. 50,000

Waiting period for pre-existing conditions 36 months 36 months 36 months
Outpatient dental treatment Not covered Not covered Covered after waiting period  of 3 years

Up to 1% of SA subject to specified limit

Life time renewability Available Available Available
Free medical check-up Once at the end of block of every continuous 4 claim free years.

Up to 1% of SA

Once at the end of block of every continuous 3 claim free years.

Up to 1% of SA subject to Rs. 5000 / insured person

Once at the end of block of every continuous 2 claim free years.

Up to 1% of SA subject to Rs. 5000 / insured person

AYUSH treatment Covered up to Rs. 20,000 Covered up to Rs. 50,000 based  on SA Covered up to Rs 50,000 based  on SA

Following are the common points for all the 3 variants of the plan:

  • Pre-hospitalisation expenses are covered for 60 days immediately before hospitalisation
  • Post-hospitalisation expenses are covered for 90 days immediately after discharge from hospital
  • Day care procedures (which do not require 24 hours hospitalisation) are covered
  • Additional cover for critical illness is available. It is optional
  • Additional cover for Critical Advantage Rider is available. It is optional
  • 2 years waiting period for specific diseases like cataract, hernia, joint replacement surgeries, surgery of hydrocele etc.
  • Life time renewability of all plan variants

Apollo Munich has a network of 4000+ hospitals where cashless treatment facility can be availed.

Health insurance plan 3: HDFC Ergo Health Suraksha Silver

HDFC ERGO Health Suraksha Silver is available on an individual basis as well as family floater basis. The plan is quite comprehensive in its coverage. The sum insured can be chosen between Rs. 3 lakh to Rs. 10 lakh. HDFC ERGO has an excellent hospital network having tie ups with 6000+ hospitals where cashless treatment can be availed. The plan does not have any sub-limits on hospital room rents, hospital expenses, diseases and consultant fees.

HDFC ERGO Health Suraksha Silver covers pre-hospitalisation expenses up to 60 days and post hospitalisation expenses up to 90 days. The reward/bonus at 5% increase in sum assured for every claim free year is less in comparison to 10% offered by Max Bupa, Apollo Munich, ICICI Lombard and Aditya Birla Health Insurance under their health insurance plans covered in this article.

There is no entry age limitation. The plan comes with lifelong renewability option.

The higher version of this plan is the Health Suraksha Gold which covers maternity expenses and offers some more additional features.

Health insurance plan 4: ICICI Lombard Complete Health Insurance

ICICI Lombard Complete Health Insurance plan is available on an individual as well as family floater basis. The plan offers sum assured in the range of Rs. 2 lakh to Rs. 10 lakh. This plan is offered in 3 variants (Option A, Option B, and Option C), the details of which are discussed in the table below.

Features of the plan

Reset benefit: All the variants of this plan come with a built-in reset benefit, if the SA chosen is above Rs. 2 lakh. Under the reset benefit feature, the sum assured will be reset up to 100% of the sum assured once in a policy year in case the sum assured is insufficient as a result of previous claims in that policy year. Refer the policy documents (brochure and policy wordings) on the insurance company website for terms and conditions related to reset benefit.

For example, Manish has bought a family floater plan for his family of four persons (self, wife and two children) with a sum assured of Rs. 4 lakh. Manish and his son fell ill during the first four months of the policy year and had to be hospitalised. During the two hospitalisation events, the entire sum assured of Rs. 4 lakhs got used. Under the reset benefit feature, the entire sum assured will be reset from Rs. 0 to Rs. 4 lakh again. This entire amount of Rs. 4 lakh can be reused again by Manish and his family during the remaining eight months of the policy year.

Pre-existing disease cover: Pre-existing diseases are covered after continuous coverage of 2 years, if the sum assured is Rs. 3 lakh and higher. If the sum assured is Rs. 2 lakh or less, then the waiting period for pre-existing disease coverage is 4 years.

The waiting period of 2 years for pre-existing disease cover is an advantage in case of this plan, as this waiting period is 3-4 years in case of most health insurance plans of other companies.

Free annual health check-up: The plan offers annual free medical check-up to the individual covered under the individual plan or the family members covered in the family floater plan. In a family floater plan, a maximum of 2 family members can avail the annual health check-up. Health check-up coupons are issued to insured persons every year which can be used to avail free health check-up at designated centres.

Sub-limits: Sub-limits can be optionally availed for a sum assured amounts up to Rs. 7 lakh. If you avail sub-limit option, you will get a discount on the premium.

No claim bonus: The plan offers 10% increase in sum assured for every claim free year subject to a maximum of 50% of base sum assured.

Wellness program: This program intends to promote, incentivise and reward the insured for healthy behaviour through wellness services. The insured can accumulate wellness points for various wellness activities as specified by the insurance company. Some of the wellness activities include preventive health check-ups, joining a gym or yoga, participating in professional sporting events and other health activities / events organised by the insurance company.

Each wellness point is worth Rs. 0.25. The wellness points can be redeemed against outpatient medical expenses like consultation charges, medicine and drugs, diagnostic expenses, dental expenses, wellness and preventive care and other miscellaneous charges not covered under any medical insurance, through the insurance company’s network providers.

Value added services: The plan provides value added services like online chat with medical practitioners, specialist e-consultation with one follow up session, diet and nutrition consultation etc.

ICICI Lombard has a network of 4500+ hospitals where the cashless treatment facility can be availed.

  Plan variant
Option A Option B Option C
Features common to all 3 plan variants Hospitalisation expenses: In-patient treatment (IPD), pre-hospitalisation (30 days) and post-hospitalisation (60 days)

Day care procedures

In-patient AYUSH treatment

Domestic road emergency ambulance

Cover for pre-existing diseases: After 2 years if SA more than Rs. 2 lakh and after 4 years if SA less than 2 lakhs

Reset benefit

Wellness program

Additional features in variant Option A and Option B Outpatient treatment

Maternity benefit

Additional features in variant Option A Hospital daily cash

Convalescence benefit

Premium Rs. 25,436 Rs. 18,551 Rs. 7,636

Optional Add-on covers: Critical illness cover, donor expense and personal accident cover are optional and can be availed on an add-on basis.

Health insurance plan 5: Aditya Birla Activ Health

Aditya Birla Group launched its standalone health insurance company, Aditya Birla Health Insurance Company in November 2016. This is a relatively newer company as compared to its contemporaries but the products offered by them are quite comprehensive in their coverage. Activ Health insurance plan is a family floater plan offered in two variants: Essential and Enhanced. The plan comes with interesting features, some of which are discussed below.

Annual health check-up: Every insured individual above 18 years of age can avail a comprehensive health check-up under the Health Check-up Program of the insurance policy. The health check-up can be availed once every year during the policy year and the charges for it are paid by the insurance company. So the company offers a FREE health check-up to every individual once in a policy year.

Some to the tests that are a part of the health check-up include Medical Examiner’s Report – MER (includes Blood Pressure (BP), Body Mass Index (BMI), Hip Waist Ratio (HWR) and smoking status), Fasting Blood Sugar, Total Cholesterol, Urine Routine, Complete Blood Count (CBC), Thyroid (TSH), ECG and few other tests. The health check-up can be availed at the insurance company’s network providers.

Chronic Management Program: Under this program an individual is covered for medical expenses related to out-patient treatment of chronic conditions like Diabetes, Asthma, High Cholesterol and Hypertension right from Day 1. If the individual is suffering from any of the above chronic conditions and if the individual is covered under the Chronic Management Program, then, the policy pays for medical consultation, diagnostic tests, and pharmacy expenses etc. These services can be availed on a cashless basis at the insurance company’s network providers. The insured doesn’t need to be hospitalised for availing the benefits of the Chronic Management Program.

The insured can avail the benefits of the Chronic Management Program, subject to certain terms and conditions which can be checked in the policy brochure and policy wording available on the insurance company’s website.

HealthReturns: The plan rewards insured people to be active and maintain good health through HealthReturns. HealthReturns can be earned by compliance with the Chronic Management Program (if applicable), Healthy HeartScore and ActiveDayz.

An individual can get a HeartScore by health assessment carried out with diagnostic tests that are a part of the annual Health Check-up Program as discussed above.

One ActiveDayz can be earned by walking 10,000 steps or burning 300 calories or spending 30 minutes at a gym / fitness centre.

An individual can get up to 30% of his / her premium in the form of HealthReturns.

HealthReturns (earned through Chronic Management Program, HeartScore and ActiveDayz) can be used for payment of the next policy premium, buying medicines, paying for diagnostic tests, paying for non-payable claims or paying for any health emergency irrespective of whether it is covered by the policy.

Reload of sum insured: Once in every policy year, the sum assured can be 100% reloaded, if the available sum assured is insufficient to pay the current claim as a result of the previous claims in that policy year.

Example: Raghav has bought the Activ Health Enhanced plan (family floater) for his family of four individuals (self, spouse and two children) for a sum assured of Rs. 5 lakh. During the first four months of the policy year, Raghav and his son fell ill and had to be hospitalised. The entire sum assured of Rs. 5 lakh got used during the 2 hospitalisation events. In this case, as per the reload feature, the sum assured will be restored from Rs. 0 to Rs. 5 lakh again for the remainder part (remaining eight months) of the policy year.

Please note that the reload feature is available in the Enhanced variant of the plan and not the Essential variant of the plan. The reload of sum insured is subject to certain terms and conditions which can be checked on the policy brochure or policy wording available on the insurance company website.

Outpatient Department (OPD) Expenses: This is an optional benefit that can be availed by paying additional premium at the time of buying the policy. Under this benefit, the insurance company covers OPD expenses (doctor consultation, diagnostic tests, pharmacy expenses etc.) up to a specified limit. If in a policy year, the complete OPD limit is not utilised, the unutilised amount is carried forward to the next year.

Maternity expenses: This is an optional cover that can be availed by paying additional premium at the time of buying the policy. The waiting period is 48 months. Coverage includes expenses related to delivery of child, pre and post natal maternity expenses. The coverage also includes new born baby expenses, vaccinations, and stem cell preservation.

Benefit of hospital room choice: At the time of buying the policy, the insured has to choose what type of hospital room he would like to get admitted in the event of hospitalisation. Later, at the time of actual hospitalisation, if the insured is admitted in a hospital room of lower category (for example shared room) than what he had opted for (example single private room) at the time of buying the policy, then he / she is eligible for a benefit. The benefit will be a certain percentage of the payable claims amount and the benefit will be transferred into the HealthReturns account of the insured.

Wellness Coach: Every insured person shall have access to wellness coaching in areas such as weight management, activity and fitness, nutrition, tobacco cessation etc. The aim of wellness coaching is to educate, empower and engage insured persons to become more aware of their health and proactively manage it. The wellness coaches will be available as a chat service on the insurance company’s mobile application and website or as a callback service.

Day care procedures: The insurance plan covers treatment for 527 day care procedures. This is higher than the number of day care procedures covered in most health insurance plans of most insurance companies. A day care treatment means medical treatment and / or surgical procedure which requires less than 24 hours of hospitalisation e.g. cataract, piles, cancer c etc.

In the below table we have presented a comparison between the two variants for your reference.

For the comparison of premium, we have taken following details: Number of people covered: 2 adults, Kids: 0, Age of the elder person: 25 years, Policy duration 1 year, SA: Rs. 10 lakhs.

Plan Variant Activ Health Essential Active Health Enhanced
Min and Max SA Min SA: Rs. 50,000

Max SA: Rs. 10 lakh

Min SA: Rs. 2 lakh

Max SA: Rs. 2 crore

Premium Rs. 12,326 Rs. 15,701
Pre-existing disease waiting period 4 years 3 years
Pre-hospitalisation medical expenses 30 days 60 days
Post-hospitalisation medical expenses 60 days 180 days
Reload of sum insured Not available Available
Sub-limit / Co-pay 20% mandatory co-payment No sub-limits or co-pay
Reward / cumulative bonus 10% increase in sum assured for every claim free year, maximum up to 100% of base sum assured 20% increase in sum assured for every claim free year, maximum up to 100% of base sum assured
Maternity benefits Available as an optional cover Available as an optional cover
Maternity benefits  waiting period 48 months 48 months
Chronic management program Available Available
OPD Available as optional benefit. Available as optional benefit.
Life time renewability Yes Yes
Free medical check-up Available, once in a policy year Available, once in a policy year
AYUSH treatment Not available Not available
HealthReturns Available Available

The Activ Health plan comes with an interesting feature of Chronic Management Program which is not being offered by other insurance companies at the moment. Some of the features that make this plan worth consideration include annual health check-up, reload of sum assured, HealthReturns, Wellness Coach, benefit of hospital room choice, OPD expenses etc.

Factors to consider for finalising a health insurance plan

Everybody’s health insurance needs are different. So, one plan cannot meet everybody’s needs. To help you select the most appropriate plan, keeping in mind your requirements, we have listed below some important points that you should consider at the time of shortlisting your health insurance plan.

  1. Individual plan or family floater?

The foremost question that one needs to cater to while investing in a health insurance plan is: Should I invest in an individual health insurance plan or a family floater health insurance plan? An individual plan covers only you, while a family floater plan can cover your family: you, spouse and kids in a single plan. Some health plans offer cover to parents, parents-in-law and siblings also.

If the family members have their own insurance cover then it is best to go for an individual plan. However, it will be more prudent to buy a family floater plan as:

  • It is less expensive as it covers the whole family at a lesser cost.
  • It will be more useful as chances of the elder members in the family getting hospitalised are more, and the insurance cover can be used to meet the medical expenses for any of the family member covered.
  1. Do I need additional health insurance if I am already covered under a corporate health plan?

Many working professionals are covered by a group health insurance plan provided by their employers. Quite often, the sum assured amount of corporate plans might not be sufficient to meet medical expenses. The cover amount mostly depends upon the employee grade. Hence it is best to get your health insurance needs evaluated with a financial planner and determine if the cover amount is sufficient to meet your health insurance needs. It is advisable to buy a separate family floater health insurance plan even though you are covered by your employer.

  1. Health insurance cover amount

One should consult a professional financial advisor to determine the health insurance sum assured that should be taken for the family. You can also get an idea about the cover amount online on health insurance websites. The cover amount is decided on several factors, some important pointers include:

  • Age
  • Demographic profile
  • Lifestyle
  • Past illness/hospitalisation
  • Family medical history
  • City you live in
  • Number of dependents and their age
  • Premium you can pay
  1. Premium amount

Premium depends on factors like age, features of the plan, sum assured chosen by you etc. There are few important points that you should analyse with regard to premium before deciding to buy a health insurance plan:

  • Higher the sum assured (SA) chosen, higher will be the premium. Hence choose the sum assured amount depending on your capacity to pay the premium.
  • The premium for same SA will be low at young age of 25 as compared to the premium that you will have to pay for same SA at 30 years of age. Hence it is best to buy a health insurance plan early in life.
  • Premium for same amount of SA varies among different health insurance plans. Hence one should shortlist the health insurance plans and then compare the premiums for same SA.
  1. Incurred claim ratio (ICR)

Incurred claim ratio (ICR) tells you about the claim paying efficiency and capacity of the health insurance company. It is the ratio between the claims paid by the company against the premium received. In simple words, ICR is the amount of claims paid by the company for every Rs. 100 received by the company as premium. Ideally, higher the ICR, greater is the trust in the company with regards to its claim paying intention and capacity. At the same time, a very high ICR may also indicate that insurance company is paying many claims and hence resulting in losses for company.

  • Insurance companies having ICR between 60-80% are considered good for buying a health insurance plan. For example, if the company has an ICR of 70, it means it is paying Rs. 70 as claims for every Rs. 100 collected as premiums and hence the company is making profits.
  • Insurance companies having ICR greater than 100% are considered to be incurring losses and may be avoided. For example, if the company has an ICR of 110, it means it is paying Rs. 110 as claims for every Rs. 100 collected as premiums and hence incurring losses.
  • Insurance companies having high ICR of 80-100% indicates though claim payment by the companies is high, the profit earned by the companies is low.
  • Insurance companies that have low ICR below 50% may also be avoided as it indicates that claims paid by the company are low or the premiums collected by the companies are high.
  1. Diseases covered

A health plan promises to reimburse you a certain amount in case you are hospitalised or have to undergo some surgery or medical treatment for some diseases. But all the health plans do not cover fully all the diseases, surgeries, diagnostic tests or consultation fees etc.

It is best to read the terms and conditions and offer document carefully for the diseases and tests that are covered and the ones that are excluded before investing in a plan.

  1. Pre-existing diseases

With the current sedentary lifestyle and increased stress in work places, there has been an increase in diagnosis of certain diseases such as blood pressure, diabetes, heart ailments at a young age. Health insurance companies impose a waiting period of 2-4 years in a health policy for acceptance of some pre-existing diseases, while some pre-existing diseases are permanently excluded.

This is an important feature of a health plan which should be thoroughly studied by an individual before investing in a health plan. The ‘pre-existing diseases’ clause asks the prospect, information with regard to:

  • Any diseases that you have been diagnosed with before the time of buying the plan
  • Any symptoms that you have been diagnosed which might later on result in the diagnosis of a disease
  • Any past illness for which you have been hospitalised and received medical treatment for
  • Any heredity medical conditions in the family
  • Any accidental injury for which you have been hospitalised in the past etc.

If the policyholder in his / her ignorance decides to withhold some information related to pre-existing diseases at the time of buying the plan, and later on if he gets diagnosed with such diseases, the insurance company has the right to reject the claim. Hence it is best to report all such relevant information at the time of buying the health plan.

There is a waiting period of 2-4 years for pre-existing diseases. Before investing in a health plan, compare the waiting period of pre-existing diseases and the one with the shortest waiting period may be considered for investment.

  1. Waiting period

Supposedly you took a health insurance plan on 2nd September and you are diagnosed with a kidney ailment and get hospitalised on 15th September, then insurance company will reject any claims made on it. The reason for this is the “waiting period of 30 days”. Most health insurance plans have a waiting period of 30 days, only after which any medical claims are admissible for payment. The exception to this clause is hospitalisation due to an accident, which can be covered from day 1.

  1. Sub-limit / Co-pay

Nowadays, quite a few health insurance plans come with a sub-limit or co-pay clause.

Sub-limit: In health plans with sub-limits, insurance companies pre-fix a certain amount for treatment up to which the company will be liable to pay. If the actual medical expenses exceed this amount, it has to be paid by the policyholder from his / her own pocket.

For example, if a health insurance policy has a sub-limit of Rs. 16,000 for cataract treatment and if the actual treatment cost comes to Rs. 20,000, then in this case, the health insurance company will pay only Rs. 16,000 and the balance Rs. 4,000 will have to be paid by the insured from his / her own pocket.

Similarly there are sub-limits on room rent, maternity expenses etc. in some health insurance plans.

Co-Pay: In health plan with co-pay option, a certain percentage (for example 10%) of total expenses has to be borne by policyholder and rest of the amount is paid by the insurance company.

It is best to choose a health plan that:

  • does not have any sub-limit or co-pay clause or
  • has the minimum sub-limit or co-pay percentage/amount
  1. Network hospitals

Insurance companies have their own list of network hospitals. If the insured gets hospitalised for treatment in one of these hospitals, then claim settlement process becomes easy. These network hospitals offer cashless claim payment benefit to policyholder. In a non-network hospital, the insured has to first pay from his / her own pocket and later the insurance company reimburses the claim amount.

Before finalising a health plan check whether the hospitals in your residential area are covered under the insurance company’s network. Also check whether the well-known hospitals in your city are covered under the insurance company’s network.

  1. Reward/Bonus

Most health insurance plans reward you in the form of bonus for every claim free year. As a bonus, insurance companies either provide:

  • Increase in the sum assured: In this case, the insurance company may increase the sum assured by 5% or 10% for every claim free year.
  • Offer discount in renewal premium: In this case, the insurance company may offer a discount of 5% or 10% in renewal premium for every claim free year.
  • Combination of both: In this case, the insurance company may increase the sum assured and offer discount in renewal premium for every claim free year.

Consider a plan that provides a combination of both.

  1. Maternity benefits

If you are at that stage of lifecycle where you will be planning a child few years down the line, then you need to select a health plan which offers maternity benefits. However, in most health plans, maternity benefits can be availed only after waiting period which may range from 1-4 years depending on the plan.

 There are certain factors that you need to check with regards to maternity benefits offered in a health plan:

  • Coverage: Health plans offer a restrictive cover for expenses related to maternity. Hence it is best to study the cover offered under maternity benefits which includes hospitalisation, room charges, consultant fees, tests carried out during pregnancy etc.
  • Waiting period: As mentioned above, maternity benefits can be availed only after a certain waiting period which may range from 1- 4 years. It is best to choose a health plan which has the lowest waiting period for availing maternity benefits.
  • Sub-limit: There is a sub-limit imposed for availing maternity benefits. Sub-limit means a certain pre-fixed amount will be paid. This amount may depend on the type of delivery (normal or caesarean), variant of the plan chosen etc.
  • Exclusions: One should study the list of exclusions under maternity benefits.
  • Hospitalisation and convalescence cover: Insurance companies place restriction on expenses and number of days of hospitalisation for convalescence that will be paid to policyholder.

Choose a plan that offers maximum maternity benefits. However this may come at a higher cost.

  1. Dental treatment covered or not

Health insurance plans offer very limited dental coverage. Cosmetic dental surgeries, dental braces and other orthodontic treatments are not covered in most health plans. Dental surgeries required to be performed in event of an accident, are covered.

Some variants of some health plans may cover some dental treatments under OPD. However there may be a waiting period for availing these benefits.

  1. Lifetime renewability

It is best to choose a health plan that offers lifetime renewability so that you can avail the benefits under the plan on an on-going basis.

  1. Free medical check-up

Choose a health plan which offers free medical check-ups to you and family members covered in the plan. Preventive health check-ups help you in monitoring your health and take corrective action, if required. Most health plans offer medical check-ups once in every 2-4 years or after every 2-4 claim free years. Some plans also offer annual health check-ups.

  1. AYUSH treatment

Alternative treatments such as Ayurveda, Unani, Homeopathy and Siddha have gained popularity in the recent years. In recognition of this, some health insurance plans cover expenses related to these alternative treatments. Hence while buying a health plan; you should check if the plan covers AYUSH treatment and the extent of the treatment.

Conclusion
All the health insurance plans that we have discussed in this article have their own unique features that make them worthy of consideration. Which is the best health insurance plan for you will depend on your requirement / needs. The plan that fulfils all or most of your requirements / needs will be the best health insurance plan for you and hence choose accordingly.

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