Financial PlanningInsurance

Arogya Sanjeevani Health Insurance Policy

Last Updated on June 25, 2020 by Gopal Gidwani

Mehul Kumar Gupta is a 30 year old marketing professional who works with a leading MNC. His wife Mehak Gupta is a 27 year old home maker. They have been blessed with a 2 year old daughter. Mehul Kumar is looking for a no fringe and a cost effective health insurance policy for himself and his family.

His requirements are simple. He is looking for a policy which can offer him basic health insurance cover as a protection against unexpected and untimely hospitalisation expenses that may arise in future. Looking at the plethora of the health insurance products available in the market, he got overwhelmed and remains undecided on the health insurance plan that he should invest in.

Recently, he came across an article in the newspaper about a new standard health insurance product – Arogya Sanjeevani Health insurance Policy. Arogya Sanjeevani Health Insurance Policy is a standard health insurance plan that has to be offered by all the insurers based on the guidelines issued by IRDAI. It is a cost effective health insurance product as compared to other health insurance plans available in the market.

Mehul Kumar is definitely interested in the product for 2 reasons; mainly:

  1. Premium is less as compared to other health insurance products and
  2. Secondly, the guidelines for the product have been fixed by IRDAI and will be standard across the product offered by all insurers

Differentiation based on insurance company rather than standard product
Even though Arogya Sanjeevani is a standard product with same features offered by all insurers, Mehul is not able to choose the insurance company from whom he should buy the policy. While the product is standard, the companies offering it are different. So the differentiation will be on company related factors like premium charged by the company, claim incurred ratio (ICR) of the company, network of hospitals of the insurance company, whether the company settles claims inhouse or through TPA etc. More on these differentiation features later in the article. First we will discuss the standard features of the product.

In this article we have made an attempt to help people like Mehul Kumar make a decision on their health insurance investment by presenting a comparison of the Arogya Sanjeevani Health Insurance Policy offered by different insurers.

Standard features of Arogya Sanjeevani Health Insurance Policy
The standard features of the Arogya Sanjeevani Health Insurance Policy offered by all the insurance companies are mentioned in the below table. Please note, even though the below image has been taken from the HDFC Ergo website, the features of the product remain same for all companies as this is a standard product for which the features have been specified by IRDAI and all companies have to offer this product with same features without making any changes.

Table: Arogya Sanjeevani Health Insurance Plan table of benefits


We will discuss these features in detail in the latter part of the article.

How to decide which company to buy Arogya Sanjeevani Health Insurance Policy from?
In the above section we have discussed the standard features of the Arogya Sanjeevani Health Insurance Policy as specified by IRDAI. Any insurance company offering this policy will have to include these features as it is without any changes. So how will you decide which company to buy this product from? In this case the differentiation will be on the basis of insurance company rather than the standard product. The differentiation will be on the basis of features like:

1) Premium: While IRDAI has specified that the product features offered will be the same by all insurance companies, IRDAI has given pricing freedom to insurance companies. So one of the major factors that you can base your decision on is the premium charged by the insurance company for the individual / family floater version of the plan. The lower the premium charged, the better. However, premium alone should not be the final deciding factor.

2) Incurred claim ratio (ICR): The incurred claim ratio (ICR) tells you about the claim paying efficiency and capacity of the general 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.

Incurred claim ratio (ICR) = Net claims incurred by a company in a year / Net Premium earned by a company in a year

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.

a) Insurance companies having ICR between 50-80% 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.
b) 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. In the initial years of health insurance business, the ICR may be higher than 100% for the company
c) 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.
d) 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.

Every year, IRDAI publishes the ICR data for all insurance companies in its annual report.

Ideally, it is best to choose an insurance company having ICR which is neither too low, nor too high, but just about right.

3) Claim process (Inhouse / TPA): Next you may check whether the insurance company is processing claims inhouse or through a third party administrator (TPA). Companies processing claims inhouse may have a slight edge over those who outsource claim processing to TPAs.

4) Network of hospitals: You should check how big is the hospital network of the insurance company. You can take cashless treatment at network hospitals. Hence, the bigger the hospital network, the better. You should also check whether the hospitals in your vicinity or the hospital of your preference is included in the insurance company’s hospital network.

5) Quality of service: Finally, the quality of service comes into the picture. You can judge the quality of service of the insurance company based on parameters like how soon is the approval given for pre-authorised requests cashless treatment, within how many days is the claim settled (in case of reimbursement claims), at the time of buying the policy how soon the company completes the medical tests and issue the policy, etc. The IRDAI has set maximum limits for these quality parameters, but you need to check how better the insurance company does as compared to these limits set by IRDAI. To know about the company’s quality of service you can check the company’s website, take feedback from existing customers, research on internet, discussion forums, social media etc.

Comparison chart of Arogya Sanjeevani policy offered by Health Insurance Companies
In the below table, I have calculated the premium for an individual policy and family floater policy (husband, wife and daughter) for a sum insured of Rs. 5 lakhs.

Features/

Companies

Max Bupa Health Insurance Company Ltd SBI General Insurance Company Ltd Star Health and Allied Insurance Ltd Manipal Cigna Health Insurance Company Ltd HDFC ERGO General Insurance Company Ltd Religare Health Insurance Company Ltd Go Digit

General Insurance Ltd

Premium Individual plan Rs. 4,722 Rs. 5,311 Rs. 4,921 Rs. 7,433 Rs. 8,675 Rs. 6,013 Rs. 3,439
Premium Family floater plan Rs. 9,457 Rs. 11,251 Rs. 9,741 Rs. 13,473 Rs. 15,182 Rs. 12,350 Rs. 6,706
Incurred claim ratio 54% 52% 63% 62% 62% 55% 11%
Claim process (Inhouse / TPA) Inhouse direct claim settlement By company and TPAs Inhouse direct claim settlement By company/TPA By company/ TPA Inhouse TPAs
Network of hospitals 4500+ 6000+ 9900+ 6500+ 10,000+ 7800+ 5900+

Important note

  • Details used for calculation of premium: Age of the husband - 30 years (date of birth: 1st January 1990), age of wife - 27 years (date of birth: 1st January 1993), age of daughter - 2 years (date of birth: 1st January 2018), sum insured: Rs. 5 lakhs
  • I have selected all family members as non-smoker, non-alcholic, non-tobacco consumers. I have selected all family members are healthy. They don’t have any pre-existing illness.
  • Premium for all companies has been sourced from respective company websites
  • Premium mentioned is inclusive of GST
  • All the premiums mentioned in this article are as on June 2020. Premium are subject to change without any prior notice. Please check the latest premium the company before purchasing the policy
  • Incurred Claim Ratio (ICR) of companies has been taken from IRDAI Annual Report 2018-19
  • Information related to claim process and network of hospitals has been sourced from respective company websites

Analysis of the General Insurance Companies
Let us analyse the above insurance companies on the basis of above 5 parameters – Premium, incurred claim ratio (ICR), claim process, network of hospitals and quality of service.

1) Max Bupa Health Insurance Company Ltd
a) Hospital Network: Max Bupa has a hospital network of more than 4500 hospitals, which in comparison to other health insurance companies quite low as compared to. But, one can get admitted in a non-network hospital and claim the reimbursement from Max Bupa later on. The number of network hospitals is expected to increase in future.
b) Claim process: Max Bupa issues a health card to insured when the policy is issued. This card is has to be presented (or policy number) to the network hospital by insured for availing cashless treatment. The hospital then contacts Max Bupa for processing the application. Max Bupa has an in-house claim management team, which them processes the request. There are no TPAs involved. The requests for cashless treatment are approved within 30 minutes which is quite good.
c) Premium: Premium of Max Bupa Health Insurance Company is quite low at Rs. 4,722 for an individual plan and Rs. 9,457 for a family floater plan in comparison to other companies.
d) Incurred Claim Ratio: The incurred claim ratio of the company is 54%, which is decent. The company is collecting adequate amount of premium and as compared to the amounts paid for settling claims.

2) SBI General Insurance Company Ltd
a) Hospital Network: SBI General Insurance Company’s list of network hospitals is more than 6000, which is higher than Max Bupa, but lower as compared to other health insurance companies.
b) Cashless Claim: During hospitalisation, for availing the cashless claim the insured can contact either SBI General Insurance Company or the assigned TPA. For cashless claims, the insured is issued a health card by SBI General Insurance. This card has to be used at the time of filling the Pre-authorisation form at hospital. The hospital then sends the form to SBI General Insurance Company / TPA for approval. The company / TPA approves the request within a specified time.
c) Premium: Premium for SBI General Insurance Arogya Sanjeevani Health Plan is Rs. 5,311 for an individual plan and Rs. 11,251 for a family family plan. The premium is higher than Max Bupa, Go Digit and Star Health and Allied Insurance Company but lower than ManipalCigna, Religare Health Insurance and HDFC Ergo.
d) Incurred claim ratio: The incurred claim ratio of SBI General Insurance Company is 52% which can be considered decent. The proportion of claim amount been paid by the company is not very high as compared to the premium amount being collected.

3) Star Health and Allied Insurance Co Ltd
a) Hospital Network: The network list of hospitals for Star Health and Allied Insurance is more than 9900 which is second highest (after HDFC Ergo) in our list of health insurance companies. This is a good thing from the perspective of cashless claims feature.
b) Claim Process: The claim process for Star Health and Allied Insurance is handled internally. There is no TPA involved. For cashless treatment, the customer has to fill a pre-authorisation form at a network hospital, which the hospital then sends to Star Health. Such requests are approved within an average turn-around-time of 2 hours.
c) Premium: The premium of Arogya Sanjeevani Policy for a 30 year old individual is Rs. 4,921 and Rs. 9,741 for family floater plan. The premium is higher as compared to Go Digit and Max Bupa but lower than other health insurance companies in our list – SBI General Insurance, Religare Health Insurance, HDFC ERGO General Insurance, and Manipal Cigna Health Insurance.
d) Incurred Claim Ratio (ICR): The Incurred Claim Ratio for Start Health and Allied Insurance for 2018-19 is 63%, which can be considered as good.

Star Health Arogya Sanjeevani Health Insurance Premium Chart

4) ManipalCigna Health Insurance Company Ltd (Formerly known as CignaTTK Health Insurance Company Limited)
a) Hospital Network: ManipalCigna has got a hospital network of more than 6500 hospitals which is quite good. However in our comparison list, the number of the network hospitals is low as compared to Star Health and Allied Insurance Company, HDFC ERGO and Religare. However the number of network hospitals is higher than Max Bupa, Go Digit, and SBI General Insurance Company.
b) Claim process: For availing cashless treatment facility, the insured needs to fill the pre-authorisation form at the network hospital, which is then sent to the company/TPA for approval. Ideally, requests for cashless claims are approved within 90 minutes.
c) Premium: The premium for ManipalCigna Arogya Sanjeevani Health Insurance plan for an individual plan is Rs. 7,433 and for a family floater plan Rs. 13,473. In our comparison list of general insurance companies, the premium charged by ManipalCigna is the second highest. The premium is lower than HDFC Ergo but higher than Max Bupa, SBI General Insurance, Star Health and Allied Insurance, Religare, and Go Digit. ManipalCigna offers a family discount of 15% for covering 2and more family members under the same policy under the individual policy option.
d) Incurred claim ratio: The incurred claim ratio of the company for the year 2018-19 is 62% which can be considered a good ratio for the company. The ratio signifies that the company is paying decent amount of claims, and at the same time, the company is collecting adequate premium for making decent profits.

5) HDFC ERGO General Insurance Company Ltd
a) Hospital Network: The list of network hospitals for HDFC ERGO is more than 10,000, which is the highest network of hospitals in our comparison list of health insurance companies.
b) Claim process: The insured can claim the cashless treatment benefit by submitting health card issued by the company at any network hospital. For availing the cashless claims, the insured needs to fill a pre-authorisation form at a network hospital. The hospital then co-ordinates wit HDFC ERGO / assigned TPA for further processing of claim. HDFC Ergo approves cashless claims within 20 minutes which is good.
c) Premium: The premium for HDFC ERGO Arogya Sanjeevani Health Insurance Policy for an individual is Rs. 8,675 and for family floater plan is Rs. 15,182. This premium is highest among all the other health insurance companies in our list. The company offers a family discount of 10%, if 2 or more of any of the eligible family members are covered under an individual sum insured policy with the company.
d) Incurred claim ratio: The Incurred claim ratio of the company is 62%, which can be considered as good. The ICR of 62% signifies that the company is paying decent amount of claims, and at the same time collecting adequate premium to make decent profits.

Premium chart for HDFC Ergo Arogya Sanjeevani Health Insurance Plan


The premiums in the above table are excluding 18% GST.

6) Religare Health Insurance Company Ltd
a) Hospital Network: The hospital network of Religare Health Insurance is spread over 7800 hospitals, which is quite good in comparison to other insurance companies.
b) Premium: The premium of Arogya Sanjeevani Health Insurance Plan is Rs. 6,013 for an individual plan and Rs. 12,350 for a family floater plan. The company offers a 2.5% - 5% family discount if more than one persons of the same family are covered in the same policy, on individual sum insured basis. The premium is high in comparison to other health insurance companies but lower than HDFC ERGO and ManipalCigna.
c) Claim process: Religare Health Insurance has in-house claim settlement process. Once the insured makes a request for cashless claim with a hospital, the request is forwarded to Religare Claim Management Team for further processing. The company usually gives approval for cashless claims within 2 hours.
d) Incurred Claim Ratio: The Incurred claim ratio of Religare Health Insurance Company is 55%, which will be categorised as decent.

7) Go Digit General Insurance Ltd
a) Hospital Network: The list of network hospitals of Go Digit General Insurance Ltd is more than 5900, which is higher than Max Bupa, but lower in comparison to other general insurance companies in our comparison list.
b) Premium: The premium of Go Digit General Insurance Ltd for Arogya Sanjeevani Health Insurance Plan is Rs. 3,439 for an individual plan and Rs. 6,706 for a family floater plan, which is lowest in comparison to all other insurance plans in our list. Go Digit is offering “age at entry” discount. The discount is 10% per year, for the first 2 years and 5% per year, for the third and fourth year. The discount is applicable for people who are less than 40 years at the time of buying the policy for the first time.
c) Claim process: For availing facility of cashless treatment, insured needs to inform either the Insurance Company or TPA. Once the company receives the request for cashless claim, it will give approval within a specified time. Go Digit has appointed Medi Assist Insurance TPA Pvt Ltd as its TPA.
d) Incurred claim ratio: The incurred claim ratio (ICR) of Go Digit for 2018-19 is 11%. This is because 2018-19 was the first year of Go Digit in health insurance business. The ICR needs to be analysed for the next few years to see how they fare.

Features of Arogya Sanjeevani Health Insurance Plan
In the above section, we have discussed the distinguishing features of some companies offering the Arogya Sanjeevani Health Insurance Plan. Now let us discuss the standard features of this product in a little detail.

1) Type of plan: Arogya Sanjeevani Health Insurance Policy offers two types of insurance plans: Individual Basis and Family Floater Basis. In individual plan, the sum insured will be applicable to one individual. In family floater plan, the sum insured will be applicable to the entire family.

2) Sum insured: The minimum sum insured is Rs. 1 lakh and in multiples of Rs. 50,000. The maximum sum insured is Rs. 5 lakhs. The policy period will be 1 year and can be renewed thereafter.

3) Category of cover: This is an indemnity insurance cover. This means, in the event of hospitalisation, the expenses will be paid by the insurance company either on cashless or reimbursement basis, subject to policy terms and conditions.

4) Eligibility: Age eligibility for Arogya Sanjeevani Health Insurance Policy is 18 - 65 years. A person above 65 years can obtain policy for family member/s, without covering self.

A family floater plan can cover the individual, legally wedded spouse, parents, parents-in-law and dependent children (age 3 months - 25 years). A parent cannot include any financially independent child above 18 years of age under his/her family floater plan. Such individuals will have to obtain their own plan, for self and their family.

5) Hospitalisation coverage: The policy cover hospitalisation expenses, if the hospitalisation is for a minimum of 24 hours. The policy will pay for hospitalisation expenses for Surgeon, Anesthetist , Medical Practitioner , Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital. These costs are covered at actuals. The policy will also pay for hospitalisation expenses for anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines and drugs, costs towards diagnostics, diagnostic imaging modalities and such similar other expenses. These costs are covered at actuals.

During hospitalisation, the policy will be subject to certain sub-limits on room rent. Room rent, boarding, nursing expenses all-inclusive as provided by the hospital / nursing home will be subject to sub-limit of 2% of the sum insured subject to a maximum of Rs. 5,000 per day. Intensive Care Unit (ICU) charges / Intensive Cardiac Care Unit (ICCU) charges all-inclusive as provided by the hospital / nursing home will be subject to a sub-limit of 5% of sum insured subject to a maximum of Rs. 10,000 per day.

6) Pre and post-hospitalisation expenses: Arogya Sanjeevani Health Insurance Policy covers pre-hospitalisation expenses for 30 days prior to the date of hospitalisation. Post-hospitalisation expenses for 60 days are covered from the date of discharge from hospital.

7) Day care procedures: The policy will cover treatment for all day care procedures. The time limit of 24 hours hospitalisation will not apply for day care procedures.

8) Cataract treatment: Arogya Sanjeevani Health Insurance Policy covers cataract treatment upto Rs. 40,000 or a limit of 25% of Sum Insured, whichever is lower, per eye under one policy year.

9) Cumulative bonus: Arogya Sanjeevani Health Insurance Policy offers bonus in the form of 5% increase in sum insured for every claim free year, upto maximum of 50% of the sum insured. In the event of claim, the cumulative bonus shall be reduced at the same rate.

10) Pre-existing disease: In Arogya Sanjeevani Health Insurance Policy, only pre-existing disease/s (PEDs) declared in the proposal form and accepted for coverage by the company shall be covered, after a waiting period of 4 years.

11) Waiting periods: After buying the policy, there will be an initial waiting period of 30 days for coverage for any illness/disease (not applicable for accidents). There will be a waiting period of 24 months for coverage of specified ailments like benign ENT disorders, hysterectomy, all internal and external benign tumours, cataract and age related eye ailments, gout and rheumatism, hernia of all types, piles and fissures, sinusitis and related disorders, varicose veins, internal congenital anomalies and some other ailments. For the complete list of ailments, please refer the policy document. There will be a waiting period of 48 months for treatment of joint replacement, age related osteoarthritis and osteoporosis.

12) Co-payment: Arogya Sanjeevani Health Insurance Policy shall be subject to a co-payment of 5% on all claims. In other words, 5% of each claim shall be paid by the insured.

13) AYUSH treatment: Expenses incurred for inpatient care treatment under - Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy treatments are covered under the policy. Here inpatient care treatment means the patient needs to be admitted to hospital. The coverage is up to the sum insured, during each policy year. AYUSH treatment is covered only in hospitals recognised by the Government or Quality Council of India or National Accreditation Board on Health.

14) Ambulance expenses: The policy will cover expenses incurred on road ambulance subject to a maximum of Rs. 2,000 per hospitalisation.

15) Grace period: For premium payment after due date, a fixed grace period of 30 days is allowed as grace period for yearly mode of premium payment. For all other modes of premium payment, a fixed period of 15 days is allowed as grace period.

Exclusions under Arogya Sanjeevani Health Insurance Policy
1) Maternity expenses: Maternity expenses are not covered under Arogya Sanjeevani Policy. This is one of the major exclusions under this policy. If you are looking for maternity cover, then you will have to look for some other policy.
2) Obesity / weight control expenses related to surgical treatment of obesity
3) Change of gender treatments
4) Cosmetic or plastic surgery expenses
5) Hazardous or adventure sports expenses
6) Breach of law expenses
7) Treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof
8) Expenses related to treatment for correction of eye sight due to refractive error
9) Sterility and infertility expenses
10) War and war like occurrence
11) Any expenses incurred on domiciliary hospitalisation and OPD treatment
12) Treatment taken outside the geographical limits of India

There are some more exclusions. For the complete list of exclusions and the details of exclusions mentioned above, refer to the policy document.

Moratorium period
As per IRDAI guidelines, after completion of eight continuous years under this policy, no look back would be applied. This period of eight years is called as moratorium period. This is simple terms means, after the expiry of moratorium period (of eight years), the insurance company cannot contest or reject any claim under this policy, except for proven fraud and permanent exclusions specified in the policy contract.

Claim process with multiple policies
If the insured is covered under multiple health insurance policies from the same or multiple insurers, the insured can make a claim under any of the policies. The insurance company selected by the insured has to settle the claim as long as the claim is within the limits of the chosen policy and according to the terms of the chosen policy.

However, the insured cannot profit by making a claim with both companies for policies covering the same risk on indemnity basis. For example, Rakesh has a health insurance policy for a sum assured of Rs. 3 lakhs with Company A and another health insurance policy for a sum assured of Rs. 4 lakhs with Company B. Rakesh gets hospitalised and the treatment cost of Rs. 2 lakhs. In this case, Rakesh can make a claim with either Company A or Company B. However, he cannot make a claim of Rs. 2 lakhs each with Company A as well as Company B and make a profit of Rs. 2 lakhs.

If the claim amount is higher than the sum insured under a single policy, then the insured will have a right to choose the insurers from whom he/she wants to claim the balance amount. For example, Rakesh has a health insurance policy for a sum assured of Rs. 3 lakhs with Company A and another health insurance policy for a sum assured of Rs. 4 lakhs with Company B. Rakesh gets hospitalised and the treatment cost is Rs. 5 lakhs. In such a case, Rakesh can choose to make a claim of Rs. 3 lakhs with Company A and the remaining claim of Rs. 2 lakhs with Company B.

Conclusion
The Arogya Sanjeevani Health Insurance Policy is a good health insurance policy to have if your health insurance requirement is to have a basic health insurance policy up to Rs. 5 lakhs. But please note that the policy comes with certain restrictions like sub-limits on room rent, co-payment of 5%, no maternity coverage. If you are looking for a health insurance without these restrictions, with maternity coverage and an overall health cover of more than Rs. 5 lakhs, then you need to consider other health insurance policies. However, for people who are young and have just started a career, Arogya Sanjeevani Health Insurance Policy is a good health insurance policy to start with.

For information on other health insurance policies, you can refer to this article titled: 5 health insurance plans for 2020.

In case of any queries please comment in the section below or write to me at [email protected]

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