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Health Insurance benefits | How to settle maximum in your health claim

health insurance benefits

Health insurance offers financial assistance to cover your medical expenses in time of health-related emergency. A good percentage of millennials are aware about the benefits of good health and adequate medical cover, still penetration of health insurance in India is quite low. I think the reason behind this low penetration i.e. 0.16% of total Population, is misguidance or lack of knowledge regarding Health Insurance. Due to which people who are already having Health policy are either not aware of their benefits under the policy or feel mentally harass when claim is not settled timely by the insurance company and all these itself demotivate people from buying or renewing the Health Insurance.

But buying a health insurance is a necessity and here is why-

Why You should Buy Health Insurance?

Since year 2020 whole world is facing Covid Pandemic and this situation adds up in expenses related to medical emergency. Earlier people used to think of Health Insurance if they are having any chronic or major ailment, but scenario has been changed now. Medical inflation is rising day by day and a single hospitalization can make your pocket significantly lighter.

cost of health issues

Let say your age is below 45 years , You are admitted in a hospital for atleast two days for food poisoning or viral fever, this would cost you atleast Rs. 50,000/- for room rent, doctor’s visit charge, medicine cost ,diagnostic charges etc in a class B city of India.

In above scenario if you are having a health insurance cover of Rs. 3 Lakhs you need to pay only approx. Rs. 5000/- and all your expenses would be covered. Isn’t it a great idea to invest in Health Insurance Premium?  Health Insurance offers you Mental Peace -Don’t worry about how you’re going to pay hefty medical expenses & hospital bills.

Type of Health Insurance

Any Citizen of India can take a health insurance policy for self, Spouse, dependent children and Parents here dependent children means if age of child is less than 25 years and marital status is single.

There are some common health plans available in Indian market commonly known as individual basis and Family Floater basis. If a person and his/her spouse covered on individual basis then the Sum Insured(SI) opted will be applicable separately and If a policy is on Floater basis, then all members covered under policy will share single Sum Insured(SI) Jointly.

For eg-     

Individual SI Basis Policy-

Neeraj and his Wife Aarushi opted health insurance plan of Rs. 2.5 lakhs on Individual S.I. basis and Neeraj got admitted in hospital for treatment of Dengue and hospital expenses cost for Rs. 1.5 lakhs .Now, after some time Aarushi got admitted in hospital for Covid treatment and hospital bill was  Rs. 2 Lakhs. Here, for remaining policy period Neeraj has Rs. 1 lakh balance in his policy whereas Aarushi has Rs. 50,000/- as balance SI.

Floater SI basis Policy-

Neeraj and his wife Aarushi opted health insurance plan of Rs. 5 Lakh on Floater SI basis. In above example if Neeraj and Aarushi got hospitalized and used Rs. 1.5 lakh and Rs. 2 Lakh for treatment, Now the balance SI under the policy will be Rs. 1.5 Lakh which can be used by any of them.

family floater health plan

Apart from Individual and Floater Plan , Group Health Insurance is also provided in the name of employer to cover his employees and their family.

Benefits under Health Insurance Policies

In todays time there are so many benefits are provided by Health Insurance Companies to cover most of your medical expenses. The most important ones are listed below.


Hospitalization Cover

Your health insurance policy generally covers all your medical expenses resulting from your hospitalization for more than a period of 24 hrs. It also covers pre and post hospitalization cost occurred. Usually, expenses related to 30 days before and 60 days after the hospitalization for the same ailment for which you got hospitalized are payable by insurance companies. These pre and post hospitalization expenses cover all the doctor recommended diagnostic test fees and medicine cost. Hospitalization expenses include diagnostic test fees, doctor’s fee, medicine cost, room rent, implants etc.

You have seen the instances where on time of buying a health policy you are promised by agent that all expenses are covered but at the time of claim settlement there is some deduction in final Payment, this is because of your eligibility of room and doctor visit charges are linked to each other.

Most of the hospitals has practice to charge doctor fees according to your room category type, higher the category higher will be doctor fees. So, in nut shell adequate policy cover is a wise thought to give while purchasing a health insurance Policy.   


Cashless/Reimbursement Treatment

Most health insurance companies have tie-ups with hospitals and medical centres. If you get admitted to one of these network hospitals, you will not have to pay anything. The insurer will handle all the bills and all you have to do is mention the policy number. This not only saves you from the hassle of arranging money in an emergency but also saves you a lot of time running around filling forms while you can be focusing on what’s important.

Another is reimbursement treatment where you can got admit in any of the hospital of your choice but for treatment you have to initially pay the bill from your pocket and later, you can claim the paid bill amount to insurance company which will reimburse the same once you submit all the requested documents. This reimbursement process can be understood in claim procedure heading.


Ambulance Cover

The cost related to ambulance services during medical emergencies is mostly covered in all health insurance plans. Check your policy to know more about ambulance cover before you buy insurance. Since this cover is also directly linked to sum insured of your policy . Generally, it is 2 to 3% of total Sum Insured. However, some of the insurance companies also provide this cover on actuals.


Tax Benefits

A health insurance policy offers the policy holder with a lot of tax benefits that fall under the section 80 D of IT Act (income tax act) of 1961. The deduction on taxes offered to the policy holder depends on factors like the premium amount, insured person’s age and many other aspects. Based on these given factors, a policy holder can claim for tax deductions & this can be from anywhere between Rs.25,000 to Rs.50,000.

*The tax benefits are subject to changes in tax laws.


Free Health Check up

You and your family members also become eligible for free health checks at the nearest network hospital of the insurance company. This benefit is provided by some of companies on three claim free renewals.


Restoration of Sum Insured

This is a very attractive benefit being provided by health Insurers where by paying a very nominal  amount of Rs. 50 to Rs.250/- you can enjoy two times of your sum insured under the policy.

Let say you have a policy of Rs. 5 lakhs , by opting this cover your policy will bear your medical expenses of upto Rs. 10 lakhs. It means you will enjoy base cover of 5 lakhs and if that get exhausted your  SI of 5 Lakh will get restored and you can avail the same if required during policy period.


Financial Security

Without insurance policy, it takes just one serious medical emergency to deplete your life savings. A health plan not only offers you peace of mind but also offers financial security. With the right health insurance policy, you can avail quality medical treatment without having to break into your savings.



Unlike the old times, today one does not need to move from one health insurance company to another, if one wants to buy the right health plan. Today we have the provision to search for our preferred health plans, compare them with each other, do our assessment & then buy the right medical insurance plan online. The icing on the cake is that you also get discounts on online health insurance purchases.


Apart from above there are many more benefits provided under different health plans such as maternity expenses, new born baby coverages, organ donor benefits, critical illness cover, Daily cash allowance while you are hospitalized,day care procedures etc. All you need is to dig deeper while purchasing a health policy to reap maximum benefit out of it.


What is not covered under your Health Insurance

While health insurance offers cover for most health ailments and diseases, there are still some exclusions under the policy. Listed below are some of the common exclusions under health plans:

·       Cosmetic procedures

·       Dental procedures – **Same can be covered if there is dental damage due to any accident.

·       Pre-existing conditions – ** Pre existing disease are covered after a waiting period of 2 to 4 years as mentioned in policy copy.

·       Congenital diseases

·       Non-prescription drugs

Injuries incurred from war, terrorism, & suicide

Factors to consider before buying a Health Insurance Policy

The decision to acquire the correct medical insurance policy is an important one and requires an in-depth examination on your end to ensure it meets your needs. The following factors must be considered closely to make the right decision:

·         Coverage Offered: The insurance coverage and the amount insured will determine the type of illnesses and operations that can be claimed during the policy term. Pay close attention to the benefits offered like hospitalization expenses, daycare expenses, covid 19 coverage, etc. before choosing the policy.

Adequate Sum Insured: The sum insured must be equivalent to your requirements. It is important to choose the plan with the highest coverage for your needs.

 It is also to note here that your room rent eligibility is usually 1 or 2% of SI of your Policy and higher the S.I. higher is your eligibility for AC Deluxe or Semi Deluxe Rooms and other heads of hospital bills such as Doctor’s fee/Visit Charges are also linked with your room charges. Hence, sum insured must be chosen wisely.

·         Type of Policy: It is vital to choose the right type of medical insurance policy online as each policy serves specific needs. As per your requirement, you can select an individual plan, a family floater plan, a group medical insurance, or a critical illness plan.


·         Waiting Period: The waiting period is the time you cannot file a claim under your medical insurance coverage. You have to wait for the deadline to expire. The waiting period typically applies to pre-existing illnesses, maternity benefits, etc. Thus, look at the Waiting Period when buying health insurance policy and choose the one with the least waiting period.



·         Co-Payment Clause: Some medical health insurance plans online consist of a Co-Payment clause. Under this clause, a portion of your coverage is borne by you. This does not reduce the total medical insurance coverage but can put pressure on you as you could be paying a part of the expenses out of your pocket when the need arises. The clause does result in a reduction of the premium amount. If you do not wish to opt for this, look for another policy.


·         Network Hospitals: Network Hospitals are directly associated with health insurance companies. They help you avail of cashless facilities at the time of need. Take a look at the network hospitals of your insurance company when choosing a medical insurance policy .



·         Lifelong Renewability: Health insurance policies are generally renewed every year. The process of renewal is quite simple & can be done entirely online. As a part of the renewal process you are required to pay your health insurance policy premium. It is important that you choose a health insurance policy coverage that has renewal options on a life-long basis.


·         Claim-Settlement Ratio: You should assess your health insurance company’s credibility based on its Claim-settlement ratio. If the ratio is higher, the more confident you can be that your claim can be fulfilled at the time of need. Ideally, a car insurance company with a claim settlement ratio of 80% is a good option.



Exclusions: Exclusions are the conditions under which the claim cannot be fulfilled. Such exclusions must be examined beforehand by the policyholder. An ideal health insurance policy is the one that meets your requirements, provides adequate coverage, and requires minimum medical insurance premium.

Health Insurance Claim Procedure

health insurance claim process

Health insurance policies have various additional benefits which include expense reimbursement & cashless treatment by the insurance company. One can file expense incurred as per following two ways-

1.      Cashless Claims-  If you are going to a network hospital or cashless hospital ,then insurance company will directly settle the claim to hospital.

2.     Reimbursement Claims– For treatment under non network hospitals, a policy holder requires to pay his hospital bill out of his own pocket and get the file with all the original documents, then this file will be forwarded to insurance company or TPA to claim the reimbursement.

In case of planned hospitalization you need to inform your insurer/TPA atleast 48 hour before taking treatment. Once TPA approves your request you can go for reimbursement or cashless treatment.

Further, in case of emergency hospitalization you have to inform your TPA within 24 hours of hospitalization and submit the pre authorization form to get TPA approval.


Documents Required for Health Insurance Claim Reimbursement

In case of hospitalization he/she needs to submit certain documents as mentioned below for making a reimbursement claim:

·       Discharge card provided by the hospital

·   In-patient hospitalization bills signed by the hospital for authenticity

·  The doctors’ prescriptions, along with medical store bills

        ·       Claim-form signed by the insured

·       A valid investigation report

·     Doctor’s prescribed consumables and disposables with complete details

·       Doctor’s consultation bills

·  Copy of the previous year insurance policy and the current year/copy of ID Card of TPA

·       Any other document(s) needed by the TPA


Here it is required to submit all the above documents as original.

FAQ about Health Insurance

Q. At what age can I get a health insurance policy?

Ans. Any Person between age of 18-65 years can purchase health insurance. For above 65 years, it will be at discretion of insurance company.


Q. What happens if I don’t pay my health insurance premium?

Ans. Your policy will lapse and continuity benefits will also be cancelled but there is grace period of 30 days provided by most of the Insurers.If you get your policy renewed within30 days of expiry date then you can enjoy continuity benefits of policy.  


Q. How many health insurance policies can I have?

Ans. There is no limit on it.


Q. Will I still be covered if I get admitted to a non-network hospital?

Ans. Yes your health insurance policy will still cover you if you are admitted to a non-network hospital. The only difference is that you will have to pay the bills and then file for reimbursement as against to getting cashless treatment.



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