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WHAT IS COVERED IN HEALTH ASSURE PLANS

 

Health Assure Plans are pure protection health assurance plan that reimburse medical expenditure incurred in a hospital. A typical health assure plan has the following features.

  • There are outer limits of cover which can change from one company to another. For instance, the outer limit for HDFC Assure Plan is Rs10 lakhs while for Star Health Assure goes all the way to Rs2 crore.
     
  • Health Assure plans offer cashless facility across their network hospitals and a hassle free reimbursement process.
     
  • Health assure plans offer a constant premium guarantee for 3 years even if you make a claim in between. In case of no claims made, a special non claims bons (NCB) is offered by way of enhancement of cover.
     
  • Health assure plans offer benefit of individual insurance and also family floaters. The limits on family floaters are normally higher than for individual plans. There is flexibility to add newly married spouse, new born, adopted child etc.
     
  • Premium payment options are flexible. Health assure plans offer one-time premium payment, annual payment or even EMIs. Normally, only people between ages of 18 and 70 are eligible for individual policies, but others can be added to family floaters.
     

What are some of the key coverages in Health Assure plans?

Typically, Health Assure plans cover the following as part of the policy.

  • Inpatient hospitalization is permitted subject to the patient staying in the hospital for minimum 24 hours.
     
  • Among the costs that are covered for inpatient reimbursement in a health assure plan are room rent (subject to limits), nursing charges, surgery charges, doctor fees, anaesthetist charges etc.
     
  • Most health assure policies cover the pre-hospitalization and post-hospitalization expenses relevant to hospitalization. These include diagnostic tests, ECG, EEG, post trauma management etc. All these are subject to actuals against submission of reports.
     
  • Some benefits are not made available to all policyholders. For example, cash benefit, wellness benefit and maternity benefits are restricted to select premium customers.

 

What is meant by hospital cash benefit, wellness benefit and multiplier benefit?

These are different things. When a policyholder is admitted for over 24 hours, the insurance company pays hospital benefit between Rs500 and Rs1,000 per day towards routine expenses. These are paid with settlement claim only. Wellness benefit is paid in the form of health check vouchers redeemable for free or discount. Most wellness benefits have a shelf life and you must use them inside that time. Wellness vouchers do not reduce your annual limit. Both cash benefits are wellness benefits are available to premium customers.

Multiplier benefit has to do with no claims bonus (NCB). For example, HDFC Health Assure multiple benefit is 50% after 1 year and 100% after 2 years of no claims. If you have a Rs10 lakh cover and don’t claim for 1 year, cover is enhanced to Rs15 lakhs and to Rs20 lakhs if no claims are made for second year. Star Health, where the maximum policy sum assured can go up to Rs2 crore, multiplier benefit varies between 10% and 20% only.

 

What happens in the event of death of the policyholder?

The rules are different for individual policies and group policies. If it is an individual health assure policy, then on the death of the policyholder the policy will automatically terminate. However, there is no refund of premiums paid, even if you have been covered only for a few months in the current year. However, in the case of a family floater, the policy will continue to be in force for other persons in the family floater. The eldest member becomes the nodal member and any adult surviving member can fill up the form for continuation of policy.

 

What is waiting period and grace period in health assure policies?

Waiting period is applicable for all members and for all health assure policies. Normally, for 30 days from the date of the policy issue, the insurance policy does not cover any disease. The only exception is injury due to accidents. There are a host of conditions that have a waiting period of 2 years or 3 years.

Normally, ENT, gynaecological, orthopaedic, gastrointestinal and skin related problems are not covered for 2 years and you can read the fine print on specific exclusions. In cases like maternity benefits and pre-existing conditions, there is a 3-year waiting period.

Grace period refers to the 30 days additional grace period given for payment of health assure premiums so they don’t lapse. It is advisable to pay premiums well in advance to get the maximum benefits of your health assure plans.

 

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