Health Insurance 330 views April 27, 2021

Health insurance plans are an absolute necessity these days given that they cover healthcare costs incurred during hospitalization, as well as before and after it. Besides, health insurance offers daily cash benefits, covers daycare procedures, ensures automatic enhancement of sum insured for every claim-free year, etc. Even as the benefits of health insurance plans are impressive, you will still need to pay for some!

Yes, these plans come with a definite sum insured amount. In case a treatment exceeds the same, you won’t get covered for the extra amount spent. Besides, these plans come with a certain capping on room rent, healthcare expenses, etc. So, if you choose a health insurance plan thinking that it will cover the entire cost, you could be unpleasantly surprised should you face a medical emergency later. In this article, we will focus on the situations where these plans won’t pay you in full.

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Check the Times When Health Insurance Plans Don’t Pay You Fully

Health insurance plans come with a capping on room rent and some healthcare expenses. Besides, some plans come with co-payment and deductible clauses. All these will require some payment from your end. Let’s read about these in detail below.

Room Rent Limit

Some health insurance plans come with a room rent limit. It means the health insurer will cover the room rent cost up to a limit specified in the policy. It could be a certain percentage of the sum insured or a flat amount. So, if the sum insured is INR 5 lakh and the room rent limit is 1%, the insurance company will pay 5,000 (5,00,000 x1%) per day. In case the room rent is INR 8,000 per day, you will need to bear the remaining INR 3,000 (8,000-5,000). But there are plans where you won’t have to contend with a room rent limit. At the same time, you can opt for a Room Rent Waiver Rider. But the rider will raise your premium outgo. So choose between these two options based on your comfort and budget.

Pre-and Post Hospitalization Expenses Get Covered for Specific Days Only

The best part about a health insurance plan is its coverage for expenses made before and after hospitalization. Once a qualified medical practitioner confirms that you need to visit before and after hospitalization and you send that confirmation letter to the insurance company, you will get reimbursement for such expenses. But you will get the cover for certain days as specified in the policy for pre and post-hospitalization. And there’s no guarantee that the expenses will happen only for days as specified in the policy document. The number of days can extend too! So, you will need to pay for extra days if that remains the case. Let’s check out the pre and post-hospitalization cover of top health insurance plans.

Health Insurance PlansPre-hospitalization LimitPost-hospitalization Limit
HDFC ERGO Health Optima RestoreUp to 60 DaysUp to 180 Days
ICICI Lombard Complete Health InsuranceUp to 30 DaysUp to 60 Days
Max Bupa ReAssure Health PlanUp to 60 DaysUp to 180 Days
Care Family Health InsuranceUp to 30 DaysUp to 60 Days
Star Health Comprehensive PlanUp to 60 DaysUp to 90 Days
Bajaj Allianz Health InsuranceUp to 60 DaysUp to 90 Days

Co-Payment Clause

Co-payment is a type of health insurance claim arrangement where policyholders agree to pay a certain portion of the medical expenses. Once they do the same, the health insurer will pay the remaining. Plans offered to senior citizens often come with a mandatory co-payment clause. However, you can opt for it voluntarily too. The only benefit of signing the co-payment clause is a reduced premium amount. But many cannot afford the treatment expenses these days. Even if you choose a plan with a co-payment clause, ensure your liability in case of a medical emergency remains the lowest.

Deductible Clause

It may sound similar to the co-payment clause but remains different. Here also, you need to pay and have a lower premium. But the claim will work differently. So, if a health insurance plan comes with a deductible clause, you won’t get covered till the time the expenses cross the deductible limit set in the policy. Let’s understand it with an example.

Suppose you have a sum insured of INR 5 lakh and the deductible limit is INR 2 Lakh. In case your treatment cost remains below INR 2 lakh, the insurance company won’t pay you anything. Whereas if the cost exceeds INR 2 lakh, the insurance company will pay the extra amount beyond 2 lakh, upto the sum insured i.e. INR 5 lakh. Suppose the treatment cost remains INR 3.50 lakh. The insurance company will then pay you INR 1.50 lakh (3.50-2) and the remaining is your liability.

Daily Cash Benefit Amount Has a Capping Too

The benefit of daily cash allowance makes health insurance plans unique and popular. But like most, it is also capped; it could be either a flat sum or a certain percentage of the sum insured. Besides, one needs to have a specified number of days of hospitalization to receive this benefit.

Capping Could Also be Based on Diseases & Treatment

Health insurance companies could fix a limit based on the type of disease and treatment too. If that remains the case, you will get covered up to a specified percentage of the sum insured or get a flat sum for the same.

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