Introduction

Having health insurance is important because coverage helps people get timely medical care and improves their lives and health. Some may believe that people always have access to medical care because they can always go to an emergency room.

But even areas with well supported safety-net care do not remove barriers to access to the same extent as does having health insurance. “Coverage matters,” concluded the Institute of Medicine (IOM) during a recent multiyear appraisal. Indeed, the prestigious IOM estimated that lack of coverage was associated with about 18,000 extra deaths per year among uninsured adults. Several points deserve emphasis.

1. Uninsured people receive less medical care and less timely care.

Overall, uninsured people get about half as much care as the privately insured, as measured in dollars spent on their care—even taking into account free care received from providers. This discrepancy holds true even when spending is adjusted for age, income, health status, and other factors. (This finding and most information presented here do not come directly from District sources, for which data are often lacking. But most patterns are believed to be generally true of all locations.)

Uninsured adults get fewer preventive and screening services and on a less timely basis. Shortfalls are documented for many types of illness or condition, including screening for cervical and breast cancer as well as testing for high blood pressure or cholesterol. Cancers, for example, are more likely to be diagnosed at a later stage of illness, when treatment is less successful.

Uninsured pregnant women use fewer prenatal services, and uninsured children and adults are less likely than their uninsured counterparts to report having a regular source of care, to see medical providers, or to receive all recommended treatment. Shortfalls are particularly notable for chronic conditions. For instance, uninsured adults with heart conditions are less likely to stay on drug therapy for high blood pressure.

Some uninsured people may decide not to obtain insurance precisely because they expect not to need medical care, so simple comparisons of the insured and uninsured can be misleading. However, many studies adjust for factors like age and health status that affect need for care.

One recent study examined people who experienced an unintentional injury or a new chronic condition—times when care is more clearly needed. Uninsured individuals were less likely to obtain any medical care, and if they did receive some initial care, they were more likely to get none of the recommended follow-up care.

Q. Is a medical checkup necessary before buying a health insurance policy?

A. A medical checkup is necessary for a new affordable health insurance policy for customers above the age of 40 or 45 years depending on the health insurer’s norms. Medical checkups are usually not needed for renewal of policies.

Q. What are the minimum and maximum policy durations?

A. Health insurance policies are general insurance policies usually issued for a period of 1 year only. However, some companies also issue a two year policy. At the end of your insurance period you must renew your policy.

Q. What is coverage amount?

A. Coverage amount is the maximum amount payable in the event of a claim. It is also known as “sum insured” and “sum assured”. The premium of the policy is dependent on the coverage amount chosen by you.

Q. My wife and children are residing at Chennai while I am here in Mumbai . Can I cover all of us in one policy?

A. Yes, you can cover the entire family under one policy. Your health insurance policy is in force across India. You must check whether there is any network hospital near to your as well as your family’s place of residence.

You must check if your insurer has a network hospital close to you or where the rest of your family resides. Network Hospitals are the hospitals that have tied up with the TPA(Third Party Administrator) for cashless settlement for expenses incurred there.

If there are no network hospitals at the place of your residence, you could opt for reimbursement mode of settlement.

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

A. Naturopathy and Homeopathy treatments are not covered under a standard health policy. The coverage is available only for allopathic treatments in recognized hospitals and nursing homes.

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

A. Health Insurance covers all diagnostic test like X- ray, MRI, blood tests etc as long they are associated with the patients stay in the hospital for at least one night. Any diagnostic tests which have been prescribed in the OPD are generally not covered.

Q. -I am young and healthy. Do I need health insurance?

A -Yes. You will need insurance. Even if you’re young, healthy and haven’t had to see a doctor in years, you will need coverage against unexpected events like accidents or an emergency.

While your health insurance coverage may/may not (depending on the policy taken) pay for things that aren’t too costly like routine doctor’s visits, the main reason to have coverage is to have protection against the large treatment expenses of serious illness or injury.

No one knows when a medical emergency might strike. It is best to buy health insurance, to save money when an emergency strikes.

Q. Is Health Insurance the same as Life Insurance?

A-No. Life Insurance protects your family (or dependents) from financial loss that may arise in the event of your untimely death/or if something happens to you.

The payout is made only post the death of the person insured or at the maturity of the policy.

Health Insurance protects you against ill health/diseases by covering the expenses you might incur (for treatment, diagnosis etc.) in case you are affected by disease or injury.

There is no payout made at maturity. Health insurance also needs to be renewed annually.

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

A_It is strongly advised to have health insurance on your own as well because of reasons of continuity. Firstly, if you change your job, you might not necessarily get health insurance from your new employer. In any case you will be exposed to health costs in the transition period between jobs.

Secondly, the track record that you have built in health insurance at your old employer will not transfer to the new company policy. Covering pre existing diseases might be a problem. In most policies pre-existing diseases are covered only from the 5th year onwards.

Therefore to avoid the above problems, it is advisable to take a private policy in addition to your company provided group health insurance policy.

Q. Is there any tax benefit that one can avail of while purchasing Health Insurance?

A-Yes, there is a tax benefit available under Section 80D of the income tax act 1961. Every tax payer can avail an annual deduction of Rs. 15,000 from taxable income for payment of Health Insurance premium for self and dependants.

For senior citizens, this deduction is Rs. 20,000. Please note that you will have to show the proof for payment of premium. (Section 80D benefit is different from the Rs 1, 00,000 exemptions under Section 80 C)

The fairer sex is not getting a fair deal despite conclusive evidence of higher life expectancy for women.

Life expectancy of males in India is 63.87 years whereas females score 66.91 years, according to data available with the ministry of health and family welfare.

“A majority of women are non-smokers, which contributes to their longer life,” says SK Sethi, vice president and director of the Insurance Brokers Association of India. But while absence of distinction between men and women on premiums is the norm, some exceptions are emerging.

Aviva Life says it offers women lower rates in case of its pure-protection product, Aviva Life Shield Plus, and charges less for certain unit-linked plans too.

LIC has an exclusive insurance product aimed at women — Jeevan Bharathi — and premiums charged are lower in this case than regular policies, says ED Rajesh Kandwal. However, such examples are few and some in the industry say it is also because of poor financial literacy standards.

One insurance broker, who asked not be named, said companies charged both men and women equal premium because most women are unaware that once they reach the middle age, they carry lower risk and, hence, should be charged less.

It is important to be an informed customer and do proper research on insurance companies and the health insurance products as there is so much variety and choice available.

Despite the variety available, there is no single policy which could fit all the needs of all individuals.

It is important to assess one’s needs from a health insurance cover and choose a cover, or covers, appropriately.

It is possible to combine different products for coverage appropriate to one’s needs.

Thus, for example, a hospitalization indemnity policy could be complemented with other insurance covers like a

• Critical illness benefit policy or
• A hospital daily cash benefit policy, which could be used to cover incidental costs not covered by hospitalization indemnity products, like excess room charges or the loss of income due to hospitalization, and
• Various other ‘non-medical’ expenses not reimbursed in health insurance plans.

Similarly, adding a personal accident cover helps maintain life style and also accommodate for additional cost of disability caused by accidental injuries.

For those already covered under a group insurance scheme by their employers, a high-deductible health insurance policy is a useful add-on which enhances coverage and provides continuity as an individual product.

When comparing policies, do not compare them just on the premium structure, but also on the details of the scope of coverage, waiting periods, exclusions, cost sharing provisions and other policy terms and conditions.

Cost sharing provisions

Health insurance policies also use cost-sharing provisions though the extent and amount of such cost sharing requirements varies between products and insurers.

The cost sharing provisions include sub-limits, which cap the maximum amount payable by the insurer for a particular procedure or cost component, as also co-payments, which are a cost-sharing requirement that provide that the insured will bear a specified percentage of the admissible costs.

Another cost sharing mechanism, a deductible provides that the insurer will not be liable for a specified rupee amount of the covered expenses, which will apply before any benefits are payable by the insurer

Always buy a health insurance policy when you are young

Buy a policy at a young age to avail richer benefits and do cover your entire family- all of them are exposed to the risk of medical costs. Make sure that you pay the premium regularly & renew your policy in time, as failure to do so may lead to loss of continuity benefits.

Fill the proposal form correctly and completely

It is important to fill the proposal form correctly and completely, including the questions on health status. Otherwise, any non-disclosure or incorrect disclosure may lead to the policy being rendered invalid or the claims on the policy being denied.

Insurers may also require a medical examination and lab tests before buying a policy, especially when the proposal form for a new health insurance policy indicates the need for the same and also where insurance is sought for the first time by a person above a certain age, say 45 or 50 years, though this varies from insurer to insurer.

It may also be required when the sum insured is sought to be raised at renewal time.

There are multiple channels available to purchase Health insurance.

• You can buy health insurance products either directly from the various channels offered by the insurance company, including online sales and telephone or
• Through IRDA licensed intermediaries like agents and brokers.

It is important to purchase health insurance only from authorized channels.

Swine Flu -Is it covered or not?

Insurance companies have come out with some clarifications and these are;

1. Cost of Tami flu is not covered as this is being given by the Government on free of cost basis.
2. Private hospitals can charge the patient for facilities like tests, beds and doctors fees. And this will be covered.
3. If admitted in a hospital and the tests are negative then nothing is payable. If positive then it is payable.
4. If it is a new policy then 30 days clause is applicable. Summary of all points is do not wait ,get health insurance policy ,otherwise be prepared to be treated in one of the government owned hospital. Wish you best of luck so that you don’t get affected with this disease.

TPA’s to deduct TDS when releasing payment to Hospitals

Recent news item indicates that this decision is being implemented. We are not going into details but we feel that the impact of this will be increase in rates by hospitals as they will find it a necessity to increase the rates with a view to handle the increased need for working capital.

The normal inflation of health acre in India is 15% per year-should we expect 18% this year. Let us wait and watch.

Medical Mafia Aug 28, 2009 issue of Fortune

It is always a pleasure to read independent articles in publications like Fortune, where unbiased article can be eye opener for all of us.

This article is worth reading – where a group comprising of doctors and lawyers handles the cases and fights with Health Insurance co’s so that the genuine or inflated claims are passed.

They manage the best of doctors assisted by lawyers to appear in the court so that the client gets paid. Ofcourse the agreed % out of this payment goes into their (lawyer/doctors) pocket. Question before us is does it happen because Health Insurance co’s are hesitant in passing of claims?

We do hope that Indian Non Life Insurance co’s as well as Health Insurance co’s will take corrective steps and we can avoid excessive role for lawyers to get the claims passed.