Must Do:: Fixing the holes in your medical insurance :: Business Line,

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A friend, who was admitted for a day into a city hospital with a fracture, had to shell out Rs 10,000 to meet the hospital bill. Being covered by his employer's group plan, he requested a reimbursement of the expenses from his employer. But, to his disappointment, he discovered that his company followed a co-payment system (where the payment is shared between employer and employee) for medical bills. If you have also been relaxing, thinking that the employer will pay up for your medical expenses, wake up!

While many employers offer group health insurance plans as a sweetener to new recruits, there may be several ifs and buts to the plan. One, quite a few policies cover the spouse, but do not pay for the medical expenses of child delivery. Two, such plans may not cover your parents or your spouse's parents. Three, they may cover the above but with the condition that the employee is willing to co-pay their bills.

Even if you buy a basic medi-claim policy (reimbursement policy) from a health insurer, you may not have comprehensive health cover. It does not, in many cases, cover expenses on child delivery and outpatient/domiciliary expenses of the insured. And note that cashless-claim benefit is offered only when treatment is received in a network hospital.

We tell you how to plug the loopholes in your medical insurance and make the most of premium you shell out.

HOW TO GET COVER

Most of us take medical insurance to tide over those emergencies that may require us to shell out a large sum unexpectedly. Buying a separate critical illness policy will help you here. A critical illness policy pays the complete sum insured under the policy in one go, on the first diagnosis of an insured illness — no waiting for reimbursement and no tension of having to file the bills. Moreover, the insurer doesn't stipulate any restriction on the purpose for which the benefit amount is to be used.

Even expenses on routine medication sometimes burn a hole in the pocket. There are some insurers who offer products that cover outpatient expenses in addition to hospitalisation expenses under a medi-claim policy.

ICICI Lombard has a medi-claim policy that covers outpatient expenses to a limit of Rs 8,000 a year, where the total benefit under the plan is Rs 3 lakh. This policy is also unique in the sense that it has only a two-year waiting period for pre-existing diseases.

The annual premium for this policy is Rs 15,000. Bajaj Allianz and Apollo Munich Health Insurance are some others that offer OPD benefits in their medi-claim plan.

It is not just the charges levied by the hospital that cost you a packet in case of hospitalisation. Those of you looking for a daily cash allowance (for diet expenses, family member's conveyance, etc.) on hospitalisation may consider the Hospital Cash policies that some companies, such as Bajaj Allianz and ICICI Lombard, offer to complement medi-claim policies.

Once you and your spouse are adequately covered, do also check if the elderly in the family are covered for their medical expenses. Dragging them into a family floater plan may not be a wise thing to do as that will mean that a ‘floating cover' is shared by all family members reducing the sums covered for each member. ICICI Lombard and Star Health are among a few others that offer a policy for the elderly.

Child-birth is almost a certainty for most of us in India, a reason why this is not covered by most standard group or medi-claim policies. If one does plan to start a family, there are specific insurance products in the market that can help. Star Health, for instance, offers such a policy.

After a waiting period of three years, this policy covers expenses relating to delivery of child, post-delivery complications, if any, and the newborn baby (on congenital disorders). The premium on a maternity plan for a married couple under age 35 is Rs 10,300 a year, for a sum insured of Rs 3 lakh.

However, if it is the ‘low' sum insured on the existing cover that is bothering you, you can top up the existing policy, says Mr Ramalingam, Head-Underwriting, Bajaj Allianz General Insurance. Most insurers offer the option of increasing the sum insured under the policy for an additional premium. It is a lot less cumbersome than going in for a new policy.

HOW TO SAVE ON PREMIUM?

A comprehensive health cover means shelling out a considerable sum towards premium every year.

A high outflow towards premium will reduce the sum available for saving and investment. One thus needs to consider the family's medical history and financial background and buy the cover that is vital.

For someone who doesn't have much financial burden and is from a family with a sound medical history, a basic medi-claim policy with OPD limits will suffice. But at the same time it is not wise to settle for a lower sum insured to save on premium costs. We give you some ideas here to optimise your health insurance:

Family floater plans are a good option to reduce the overall premium outgo towards a health plan. There is a single sum assured that can be shared among the members (no individual upper limits) without the need to pay up premium for each insured member separately.

Sample this: With Bajaj Allianz a medi-claim policy of sum insured Rs 2 lakh will come for a cost of Rs 2,338 for a male of 25 years age. A medi-claim plan for his wife may cost him another Rs 2,000/2,500. So, for Rs 4,092 he can take a family floater plan that will cover not just him and his spouse but also his child. Though normally family floater plans accept to a maximum of two adults and two kids under the plan, Max Bupa's recent product covers up to 13 members of a family under the plan.

No-claim bonus will also lower the individual's premium cost to a considerable extent if he continues without a single claim on the policy for a few years in a row. No-claim bonus is given in the form of higher sum insured or discount on premium in the subsequent year. The discount on premium goes as high as 25 per cent in the case of some insurers on five or more continuous years of no-claim.

Indemnity policy is the choice of smart people who do not want to rely on notional estimates of a future medical claim to arrive at a sum assured. Not many insurers offer an indemnity plan under their critical illness policy. Here the policy holder is paid the actual amount incurred on hospitalisation rather than the sum insured.

Mr Subrahmanyam B, Vice President and Head, Health Vertical of Bharti AXA General Insurance which offers an indemnity plan says that premiums of indemnity policies tend to be typically lower than those under benefit policies for the same sum insured.

Sample this: A 25-year-old man who takes a critical illness policy with Bharti AXA will shell out Rs 650 if he opts for an indemnity plan and Rs 722 for the same sum insured if he chooses the benefit option.