What is Covered in the Best Health Insurance Plan?

What is Covered in the Best Health Insurance Plan?
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Health insurance is basically a contract between an individual and an insurance provider in which the insurer agrees to pay for some or all of the individual’s medical expenses, up to a predefined limit. The health policy can cover a wide range of expenses, including hospitalization, doctor’s visits, prescription drugs, and other medical costs. The best health insurance policy may also include tax breaks, such as the Section 80D deduction, which helps the insured to deduct a portion of their health insurance premiums from their taxable income. This facilitates savings and helps seek the required medical attention.

On that note let’s check what entails the best health insurance plan.

Scope of Health Insurance Plan

The best health insurance plan covers the following in its scope of coverage –

Pre-existing Illnesses

The insured can file a claim for expenses incurred for the treatment of any pre-existing illness or medical condition once the policy’s waiting period has expired.

Pre and Post-Hospitalisation Expenses

Health insurance typically covers medical expenses that are incurred before, during, and after hospitalization. This includes expenses such as blood tests, x-rays, other health screenings, medication, and preventive health check-ups.

Preventive Health Check-ups

Health insurance providers may offer preventive care benefits, such as annual health checkups.

Inpatient hospitalization expenses

These expenses are covered under the insurance plan for the treatment of an injury or illness. However, the reimbursement is only available if the patient was hospitalized for more than 24 hours.

Ambulance Fees

While most health insurance plans cover ambulance transportation, the exact amount of coverage may be limited.

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Maternity Coverage

The insured is reimbursed for all medical expenses incurred during pregnancy and childbirth, as well as for the newborn baby.

Day-care Procedures

Health insurance plans typically cover daycare treatments, which are medical procedures that do not require hospitalization for more than 24 hours. Some common daycare treatments include eye surgery, dialysis, and other procedures listed in the policy agreement.

Home Care Coverage

Health insurance plans may cover the cost of receiving medical care at home, as advised by a doctor. Additionally, they may cover medical expenses incurred for Ayurveda, Homeopathy, Unani, or Siddha treatments, subject to a certain limit. They may also cover mental illnesses, as defined by the Mental Healthcare Act of 2017.

Exclusions of Health Insurance Plan

The following healthcare costs and charges are not covered under the health insurance plans –

  • Claims made during the first 30 days of purchasing a health insurance policy, unless it is an accidental emergency.
  • Pre-existing conditions are medical conditions that the policy buyer had before they purchased the health insurance policy. Coverage for pre-existing conditions may be subject to a waiting period of up to 4 years.
  • Critical illness is a serious illness that can have a major impact on their life. Coverage for critical illness may be subject to a waiting period of 90 days.
  • Injuries caused by war, terrorism, or nuclear activity.
  • Suicide attempts or self-inflicted injuries.
  • Terminal illnesses, such as AIDS.
  • Cosmetic or plastic surgery, such as breast augmentation or liposuction.
  • Dental or eye surgery, unless it is medically necessary.
  • Common diseases, such as the flu or a cold.
  • Bed rest and rehabilitation.
  • Treatment or diagnostic testing that is not medically necessary.
  • Follow-up procedures after treatment.
  • Injuries caused by adventure sports, such as skiing or skydiving.
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Having an idea of these inclusions and exclusions of policy helps understand insurance meaning and its scope for an intending buyer better and allows them to make informed decisions.

What to Check Before Getting a Health Insurance Plan

Check these factors in detail before getting a health insurance plan –

  • Sum Insured

The sum insured is an important consideration when choosing health insurance coverage. The amount of sum insured should be sufficient to cover one’s expected medical expenses, taking into account the current rate of inflation. A minimum sum insured of Rs.10 lakhs is recommended, and a maximum of Rs.crore. A higher sum insured will provide better coverage, especially for family floater policies and senior citizen insurance plans.

  • Policy Type

There are many different types of health insurance available today, so it is important to choose one that meets an individual’s specific needs. Some of the most common types of health insurance include:

Individual health insurance: This type of insurance covers an individual, and he/she can choose the level of coverage that best suits their needs.

Senior citizen health insurance: This type of insurance is designed for people over the age of 60, and it typically offers more comprehensive coverage than individual health insurance.

Family floater: This type of insurance covers the entire family, and it can be a good option if they have dependents.

Critical illness plans: This type of insurance pays out a lump sum if the buyers are diagnosed with a critical illness, such as cancer or heart disease.

Individuals can add a top-up to their existing health plan for extended coverage. This can be helpful if their sum insured gets exhausted during ongoing treatment.

  • Waiting Period Clause
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Health insurance policies typically have an initial waiting period, during which no claims are covered, except for accidental hospitalization. This is to prevent people from buying health insurance just before they need it. The waiting period can range from 1 month to 4 years, depending on the policy. It is important to choose a policy with a shorter waiting period to ensure that one’s covered as soon as possible.

  • Room Rent Sub-limits

The sub-limit in a health insurance policy is up to the amount that the insurance company will pay for a specific type of expense, such as room rent. For example, a policy with a room rent sub-limit of 1% of the sum insured would only pay up to Rs 3,000 per day for room rent, even if the total cost of the stay was higher. This is why it is important to choose a health plan with no or few sub-limits, to curtail unexpected expenses.

  • Network of Cashless Hospitals

Individuals should verify the network of hospitals associated with their insurance provider to determine which ones accept cashless claims. The greater the number of network hospitals in one’s region, the higher their chances of receiving cashless hospitalization benefits.

  • Claim Settlement Ratio

A policy provider’s claim settlement ratio is an important factor to consider when choosing an insurance plan. A high claim settlement ratio indicates that the insurer is more likely to settle claims promptly and fairly. A claim settlement ratio of over 80% is generally considered to be good.

When looking for the best health insurance plan, policyholders should consider their individual needs and requirements. They should carefully review the plan’s terms and conditions to ensure that it meets their needs.

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