1. How does Health Insurance Work?
Health insurance is a type of non-life insurance that covers your medical expenses arising
out of hospitalisation following sickness or accident. A health insurance policy is a contract
between an insurance company (called the insurer) and the persons insured or their
families. This contract, usually detailed in the Health Insurance Policy, lays out the terms and
conditions under which the insurer agrees to provide health insurance cover at a specific
“premium” – or the cost of the contract you need to pay.
Health insurance as defined by Wikipedia is “insurance that covers the whole or a part of
the risk of a person incurring medical expenses, spreading the risk over a large number of
persons.” In other words, it’s an insurance policy that covers an individual or a family against
medical expenses where the policyholder chooses a coverage under an insurance plan and
he/she will be reimbursed the expenses incurred for treatment of an injury or illness.
2. What are different kinds of Health Insurance in India?
Health insurance policies in India cover the expenses incurred on treatment that requires
hospitalization. However, many specialised health policies are now available which offer a
range of medical insurance covers, depending on the specific need of the customer. Indian
insurance companies provide health insurance in one of these three forms:
• Direct payment to the hospital (also known as cashless feature)
• Reimburses expenses associated with hospital bills and receipts
• Fixed benefit on the occurrence of an illness (e.g., critical illness policies)
The type and amount of health care costs that are covered by the health plan are specified
in advance.
3. What factors determine Health Insurance premiums?
The age of the insured is a major factor that determines the premium. The older you are,
the higher your premium will cost, since the older you get, the more likely you are to fall ill
and claim insurance.
If you have a pre-existing medical condition (like hypertension, diabetes, etc), it impacts
your premium and you may have to pay a higher amount to get suitable coverage.
The number of years a health policy remains claim-free is also a factor in determining the
cost of the premium. You get lower premium rates or a discount for a higher number of
claim-free years.
Health insurance companies classify cities into zones and premiums can also vary,
depending on which city you live in. Those staying in a Metro or Tier I city usually have to
pay higher premiums.
4. Can an individual have multiple Health policies?
Yes, one person can have multiple health insurance policies, but you can claim only from any
one of the policies at a time. A typical example of this is group medical policies provided by
employers to their staff. Many employees choose to have their individual or family floater
policies in addition to the employer’s group policy. Customers can also opt for additional
Top-Up insurance plans to bolster their base policies.
5. Why is Health Insurance Important?
Given the current cost of healthcare, and the sharp rise in these costs every year, everyone
needs to have health insurance for themselves and their family members without exception.
Irrespective of your economic or social standing, you can choose from a health plan that
suits your needs and pockets. Health insurance can protect your family from financial
troubles from unexpected expenses of hospitalization or treatment of a critical illness.
Everyone is exposed daily to various health hazards and lifestyle illnesses and medical
emergencies can strike anyone without any prior warning. Importantly, the cost of
healthcare is also increasingly expensive, with emphasis on technology, new procedures,
and more effective medicines that have increased the costs of quality healthcare. Health
insurance makes expensive healthcare possible, for a fraction of the cost of hospitalisation.
6. What is a Family Floater policy?
Family Floater is a type of health policy that covers the medical expenses of an entire family
under a single sum insured. The premise being (except in the Covid scenario) that every
member of the family doesn’t need to utilise the available insurance in each policy year.
So a family floater is a policy for the entire family, which can be utilised by any/all insured,
subject to the maximum of policy sum insured. Often family floater plans are better (and
cheaper) than buying separate individual plans. Family Floater plan is an ideal option for
families where the eldest member of the family is under 45 years old since premiums in
family floater policies are calculated basis the age of the oldest person covered.
7. What is Cashless Facility under Health Insurance?
Most insurance companies have a designated network of hospitals across the country in
partnership with their Third Party Administrator (TPA). For policyholders who undergo
treatment in these network hospitals, the insurer’s TPA makes arrangements for the
payment directly to the hospital and there is no need for the insured person to pay hospital
bills. This is known as a cashless treatment facility.
In a cashless settlement, a policyholder needs to pay for expenses not covered by sub-limits
under specific clauses mentioned in the policy. These are paid directly to the hospital at the
time of discharge. For health policies, a cashless facility is only available at Network
Hospitals. In case the policyholder opts for treatment in a non-network hospital, they need
to settle the bills and then submit them for reimbursement from the insurance company.
8. What features should I consider while buying Health Insurance?
Here are some key features and benefits you should consider before buying a health
insurance plan. To know more about these features, you can read up insurance blogs and
refer to help articles available online. You can also test your current health policy benefits on
www.testmypolicy.com
•Exclusions under the policy for specific diseases
•Room Rent & Treatment Sub-Limits
•Pre-existing Disease Waiting Periods
•Restoration Benefit especially for family floater policies
•Cashless Hospital Network of the Insurer
•Additional benefits like Health Check-Ups offered by the insurer
•Claims Settlement Ratio and Reputation of the Insurance company
9. What are the different types of Health Insurance plans available?
Health insurance plans come in many shapes and sizes to suit the needs of a variety of
customers. From micro-insurance policies in rural areas, mediclaim policies that only cover
hospitalisation expenses, specialised health policies with fixed claims (like critical illness
plans), group plans, and health schemes offered by the Government and Corporates.
Comprehensive Plans
Most private insurance companies (operating as non-life or general insurance) offer both
basic and comprehensive health policies with sum insured ranging from ₹1 lac to ₹1 crore
(or more). Comprehensive policies typically offer higher flexibility, better coverage and
include several additional benefits like health checks, restoration of the sum insured,
no-claim bonuses, etc.
A health policy is meant to cover the actual cost of the treatment for hospital admissions
during the policy period. Such policies are available for individual, multiple individual or
family floater basis, where the sum insured is shared across the family members. While
most health insurance policies are valid for a duration of one year, policies can also be
bought for a longer duration of up to 3 years.
Top Up or Super Top Up
Another type of health policy one can opt for is a Top Up or Super Top Up plan. These are
useful to increase the sum insured coverage of basic health plans without the need to buy
another policy. The Top Up policy only comes into force once you have exhausted the sum
assured of your basic health plan, hence these policies cost much lower than basic plans
with a higher sum insured.
Critical Illness Policy
There are also specialised critical illness policies available to cover high costs of cardiac care,
cancer treatment, or Covid risks. These policies usually provide a lumpsum amount to the
policyholder when on the diagnosis of a specified illness or on undergoing a specified
procedure. They help mitigate various direct and indirect financial consequences of a critical
illness. Policies for specific customer groups like senior citizens are also offered by most
insurance companies.
10. Are there tax benefits if one opts for Health Insurance?
Yes, the premium you pay for health insurance offers attractive tax benefits as an added
incentive. Under Section 80D of the Income Tax Act, you are eligible to claim a deduction
from your taxable income up to ₹15,000 for the payment of Health Insurance premium for
self, spouse, and dependent children. One can also claim a deduction of an additional
₹15,000 if they are paying the health insurance premium on behalf of their parents,
assuming parents are senior citizens.
11. What are common exclusions in health insurance policies?
It’s important to understand what your health insurance policy covers. But it’s even more
important to be aware of the exclusions or what is not covered under the health plan.
Generally, pre-existing diseases (different across insurers and plans) are excluded or impose
a waiting period before they can be claimed. Specific treatments for certain diseases are
also excluded from the first year of coverage or have a waiting period. These exclusions are
usually listed in your policy document. To know what kind of waiting periods your policy
enforces, you can test your policy at www.testmypolicy.com
There are also certain standard exclusions in most health policies such as:
•Treatment of medical conditions arising due to hazardous activities
•External Congenital Anomaly
•Convalescence & Rehabilitation
•Cosmetic or Plastic Surgery
•Dental/Oral Surgery
•Eyesight & Optical Services
•Experimental Treatment
•Hormone Replacement Therapy
•Obesity and Weight Control Programs
•Reproductive Medicine & other Maternity Expenses
•Robotic-Assisted Surgery
•Sexually transmitted Infections & diseases
•Sleep Disorders
•Substance- related and Addictive Disorders
•Treatment at Non Recognized Physician or Hospital
•Cost of consumables like swabs, disposables, PPE kits, etc.
For the exact list of what your policy covers or not, you must read the policy document
carefully.
12. What is co-payment?
Some policies offer a lower premium when you opt for the co-payment feature. Co-payment
is a payment sharing clause in your policy in which the policyholder agrees to co-pay a part
or percentage of the claim amount. Co-pay can vary between 15% to 30% depending on
your health insurance plan. E.g., if you have a policy in which the co-payment is fixed at 20%
and your claimable hospital bill is Rs. 1 lakh, you will need to pay Rs. 20,000 or 20% of the
claimable amount and the rest will be paid by your insurance company.
13. Is there a waiting period for claims under health insurance?
A waiting period is the duration of time a policyholder must wait before some or all of their
coverage comes into effect. You will not receive benefits for claims filed during the waiting
period. There are generally different waiting periods in most health insurance policies, like
30 days waiting period at the inception of a policy, when hospitalization charges are not
payable by the insurance companies, except in case of an accident. Similarly, there are
waiting periods for maternity, pre-existing diseases, etc.
14. What is Pre-existing Disease mentioned in a health insurance policy?
When you buy a health policy for the first time, the insurance companies ask you to declare
if you have been diagnosed with or treated for any chronic diseases. These are known as
pre-existing diseases. Most insurance companies in India exclude coverage for pre-existing
diseases for a defined period, which is specified at the beginning of the policy. Treatment
cost for pre-existing diseases is usually covered after a few years of insurance coverage.
While it varies from company to company, pre-existing condition coverage can be covered
after 2 to 4 years, provided you renew the policy with the same insurer. Waiting periods for
pre-existing medical conditions can be from 24 to 48 months, after which pre-existing
diseases and any treatments arising out of such conditions are covered. Some new
comprehensive health plans cover pre-existing diseases from the first year of policy
purchase too. One must be aware of the waiting periods and the sum insured for treatment
due to pre-existing conditions as it impacts your health coverage. One quick way to do that
is to test your policy on www.testmypolicy.com
15. Should I disclose my pre-existing diseases when buying a policy?
At the time of applying for a health policy, you must disclose any illnesses for which you are
currently undergoing treatment or have had treatment in the past. Insurance companies
refer to such health issues as pre-existing illnesses. So yes, it is necessary to disclose your
existing health problems before buying a policy. Since the insurers are not liable to any of
the alteration of facts later on.
16. Will I have medical coverage if I don’t renew my policy date before the expiry date?
No. Your medical cover is compromised if you fail to renew your policy. Ideally, your renewal
premium should be paid before the expiry date of the current year’s policy. However,
insurance companies offer an additional 15 days as Grace Period after the expiry date of the
policy to allow payment of the renewal premium. Failure to make the premium payment
even during this grace period results in the policy lapsing. Also, your health coverage would
not be available for the period for which no premium is received by the insurance company.
17. What does Insurance portability mean?
The Insurance Regulatory and Development Authority of India (IRDAI) is a regulatory body
that issues guidelines to insurance companies in India. One such guideline issued by IRDAI
refers to Insurance Portability. In simple terms, insurance portability is similar to mobile
number portability, which allows you to change your telecom operator without changing
your mobile number. IRDAI mandates that a policyholder should have the right to port
his/her health policy to another insurer without losing the benefits you have accumulated.
Before insurance portability, such a move would have resulted in a policyholder losing
benefits like the waiting period for covering Pre-existing Diseases. With insurance
portability, you can port your policy to any other insurer of your choice and the new insurer
“shall allow for credit gained by the insured for pre-existing condition(s) in terms of waiting
period”. This applies not only when you move from one insurer to another but also from one
plan to another with the same insurer.
18. What are the terms and conditions for Insurance portability?
The following policyholder rights and conditions have been mandated by IRDAI with regards
to insurance portability.
Rights of the Policyholder
•You can port your policy from and to any general insurance company or specialised
health insurance company
•You can port any individual or family floater policy
•Your new insurer has to give you the credit relating to the waiting period for
pre-existing conditions that you have gained with the old insurer
•Your new insurer has to insure you at least up to the sum insured under the old
policy
•Porting by the new insurer must be completed as per the timelines prescribed in the
IRDA’s regulations and guidelines
Conditions applicable for policy porting
•You can port the policy only at the time of renewal, at least 45 days before renewal is
due
•Except for the waiting period credit, the new policy terms (including premium) are at the
discretion of the new insurance company
•To port your health policy, approach your current insurer at least 45 days before your
renewal is due
•Give a written intimation to inform your old insurance company of the shift
•Specify company to which you want to shift the policy
•Renew your policy without a break (30 day grace period if porting is under process)
19. What are Pre and Post Hospitalisation expenses?
One of the key benefits of a health insurance policy is that it can also cover medical
expenses incurred before and after hospitalisation. These include the cost of consultation,
medicines, treatments, or therapies recommended by the doctor in charge of your hospital
treatment.
Most policies cover pre-hospitalisation treatment cost up to 30 days and post hospitalisation
costs for 60 or 90 days. Medical expenses incurred pre and post hospitalisation are
considered as part of the claim provided they relate to the illness for which treatment was
sought and a claim filed by the policyholder.
20. What are Network Hospitals?
Insurance companies have agreements with prominent hospitals through their Third Party
Administrators (TPA) for providing Cashless treatment to the policyholders. These hospitals
raise the policyholder’s medical bills directly to the TPA and the insured doesn’t need to pay
the hospitals for the treatment. Such hospitals are referred to as Network Hospitals.
The advantage of going to your insurance company’s network hospital is that they offer fixed
and pre-decided charges for treatments/surgeries etc. and are generally better committed
to quality healthcare.
21. What are Day Care procedures and will my policy cover them?
With the advances in medical science, many treatments which required hospitalisation can
now be treated in a day. A day care procedure refers to any minor surgery or medical
procedure that can be completed in less than 24 hours and doesn’t need the patient to be
hospitalised.
Since health policies usually require a min. 24 hours hospitalisation to file a claim, an
exhaustive list of day care procedures has been added under medical policy coverage. Today,
all insurance companies cover day care procedures, but the exact number and kinds of
treatments covered vary with insurers. To see which Day Care procedures are covered by
your insurer, please read your policy terms and conditions. For further information, you can
always compare the benefits and features of your policy at www.testmypolicy.com
22. Who do I need to call in an emergency hospitalisation?
All medical insurance insurers have appointed a Third Party Administrator (TPA) to manage
claims and be the first point of call for a policyholder. Some insurance companies outsource
TPA duties and a few have in-house TPAs for faster settlement of claims. Your policy
documents and health cards will usually have the contact details of your insurer’s TPA. If you
can’t reach the TPA for some reason, you can always call the insurance company directly on
their Toll-Free Assistance numbers to inform them about your hospitalisation.
1. What is Test My Policy?
Test My Policy or TMP is a specialized insurance information website that helps simplify and check your existing health insurance policy for the gaps in your coverage.
Since 99% of people with health insurance are not familiar with the legal language in their policy documents, Test My Policy helps you in the following ways:
•Check for conditions and limitations your existing policy may impose
•Check whether you’re adequately covered based on your age, life stage & dependants
•Check if the premium you’re paying is optimal or not
•Recommend the actions you can take to fill the gaps in your current policy
•Recommend alternative health policy plans you can port to at similar premiums
•Enable the online purchase of health insurance policy and add-on benefits
2. How can Test My Policy help me?
Test My Policy simply makes checking your health insurance coverage easy for you. Just enter your existing policy details and we will analyse your policy for the benefits it offers and the limitations it imposes.
Our intelligent algorithm automatically makes feature comparisons with other health plans at similar price points from major insurance companies and tells you what benefits your policy offers for the premium you pay.
TMP also assists you by simplifying legal terms in your policy document. This helps you understand insurance jargon in simpler words so you know what your policy will or will not cover.
Finally, to help you make an informed choice, TMP recommends alternative plans you can consider for porting your policy up to 45 days before your next renewal and completes the purchase process online. Test My Policy’s support team is here to guide you at any and every step.
3. Why test my health policy on TestMyPolicy.com?
Good question. Unfortunately, the Indian health insurance industry is plagued with customers not having the right information or having information too complex to decode. As a result, customers find it difficult to make an informed decision based on their specific health cover needs.
Before deciding on a health policy, customers are often promised hyped up benefits or wrong benefits by the insurance seller. Since insurance sales are mainly done by individual insurance agents, over-selling of plans is a common complaint among customers. This is mainly because most agents are tied to one insurance company and therefore offer little choices amongst insurers.
Most agents also tend to sell the plans that get them the highest commissions for themselves (obviously!). Hence among agents, there is no need real understanding of what your actual insurance needs are, and which plan works best for you.
4. What details can I get about my health insurance policy?
TestMyPolicy.com runs on an intelligent algorithm that analyses your current health policy data and compares your existing policy with hundreds of health insurance plans. Based on this comparison, we distil the data to answer three simple questions you should know:
1.Is my health cover adequate?
2.Am I paying the optimum premium?
3.Does my policy impose any limits?
Besides answering the above questions, TMP details out specific benefits your policy offers and important features it may be lacking. It also recommends steps you can take to cover the gaps in your policy. TMP also gives you a list of alternative health plans you can consider porting your policy to.
5. How can I use the Policy Test Report?
After analysing your policy data with an intelligent algorithm, TMP auto-generates a detailed Policy Test Report for you. This report is sent to you via email or WhatsApp.
The TMP report helps you understand your policy better in terms of features and benefits and also gives you recommendations to plug the gaps in your current policy. E.g., if your health policy sum insured is not adequate, the report can recommend top-up plans you can add to improve your policy coverage.
TMP Policy Test Report recommendations are purely made on available customer data with no preferential bias to any insurance plan or company.
6. How much do I have to pay to Test My Policy for its services?
Test My Policy services are free of cost to our customers. You do not have to pay anything to test your health policy.
7. How do you make money then?
Test My Policy earns from service charges paid by the insurance companies you decide to buy insurance from.
8. If I need assistance, what should I do?
You can go through our FAQs. You might find your answer there. You can also call us at +917710804888. or email us at support@testmypolicy.com and our representative will get in touch with you to help you through.
9. What if need any clarifications on my Test Policy Report?
No problem, we’re happy to assist you. Our trained insurance experts offer consultation and advice for anything related to your policy. You can WhatsApp on +917710804888 or email us at support@testmypolicy.com and we will try to resolve your queries as soon as possible.
10. How safe is my information with Test My Policy?
Your private data is protected using bank-level security and is totally safe with Test My Policy. Please refer to our Privacy Policy for details.
11. Why do I have to upload my health policy to test it?
Your health policy document has the complete list of features, benefits and exclusions in your policy. As long you remember key details of your policy, you can simply fill them online on www.testmypolicy.com and we will generate the test results for you. But if you’re not sure about your plan details, it would be best to upload your policy document or email it to us. Most policy documents are emailed to you by your insurer, or sent as a physical copy within a few days of policy purchase.
12. Can I make a claim even if the policy documents haven’t reached me?
You need to know your policy number at the time of claim, even if the policy document has not reached you provided you fulfil the waiting period norms as mentioned in the policy. If the policy documents have not reached you because your proposal for insurance has not been accepted, you cannot make a claim.
13. Can I file a policy claim with Test My Policy?
No. You need to present the claim to your insurance company. Although as facilitators, we can guide you with the step-by-step procedure for making a claim.
For policies with a cashless facility, you need to inform the TPA of the claims and get a reference number within the stipulated time to avail of the benefit. TPA number is given on the information booklet as well as your health cards received by you.
For reimbursements or other claims without cashless facility, you need to inform the insurance company, fill up the claims form attach necessary documents like original medical bills and invoice, etc. as the case may be, and send it to your insurance company.