HOW DOES HEALTH INSURANCE WORKS IN INDIA

In India, health insurance coverage is relatively low compared to global standards. According to recent statistics, around 30% of Indians have some form of health insurance. The rising frequency of accidents and illnesses highlights the growing need for comprehensive health coverage.

With the increase in road traffic accidents and lifestyle-related diseases, the pressure on the healthcare system is mounting. For instance, consider a scenario where a middle-class family faces a severe car accident. The hospital bills for surgeries, intensive care, and follow-up treatments can be substantial. Without health insurance, the financial burden of such an event could be overwhelming. Even those with insurance might struggle if their coverage is inadequate or if the claim process is cumbersome.

In response to rising accident rates and the need for robust health coverage, the government and insurers are pushing for increased health insurance awareness and affordability. Enhanced coverage options, including accident-specific plans, are also being developed to better protect individuals against unexpected medical expenses.

Understand the Information of Health Insurance and How It Works

Health insurance in India functions as a financial safety net to cover medical expenses. It operates through various plans offered by both private and public insurance companies.

• Coverage

Health insurance typically covers hospitalization expenses, including room charges, doctor fees, surgeries, and sometimes outpatient consultations and preventive health check-ups. Plans can also include add-ons like critical illness coverage and maternity benefits.

• Premiums

Individuals or families have to pay a regular premium to the insurance provider. Insurance premium amounts vary based on the coverage, sum insured, age, and health condition of the insured.

• Claim Process

When a policyholder needs medical treatment, they can either opt for cashless hospitalization at network hospitals or pay out-of-pocket and file a reimbursement claim with the insurer.

• Pre-existing Conditions

Health policies generally have a waiting period for pre-existing conditions and this waiting period health insurance claims for pre-existing conditions can be made.

• No Claim Bonus

Some policies offer a no-claim bonus, increasing the sum insured or reducing the premium for every claim-free year.

• Exclusions

Certain conditions and treatments might not be covered, and understanding these exclusions is crucial.

Typically, a health insurance policy covers hospitalization costs, day care procedures, organ donor expenses, ambulance charges, maternity expenses, and AYUSH treatments. However, the extent of coverage varies between different mediclaim policies.

Additionally, health insurance plans often offer optional add-on covers that can enhance your policy. Common add-ons include reduced waiting periods for pre-existing conditions, critical illness cover, OPD coverage, and hospital daily cash benefits.

Government Health Insurance Schemes in India

India has several government health insurance schemes designed to make healthcare more accessible and affordable:

1. Pradhan Mantri Jan Arogya Yojana (PMJAY)

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana scheme provides free health coverage of up to ₹5 lakhs per family per year for secondary and tertiary care hospitalizations. It targets low-income families and covers a wide range of treatments, including hospital stays, surgeries, and more.

2. Pradhan Mantri Suraksha Bima Yojana (PMSBY)

The PMSBY scheme offers accidental death and disability coverage. It provides a lump sum payment of ₹2 lakhs for accidental death or disability due to an accident.

3. National Health Protection Scheme (NHPS)

The NHPS is a large-scale scheme under Ayushman Bharat aimed at providing health coverage to vulnerable populations, ensuring that the cost of healthcare does not become a barrier for those in need.

These schemes have helped millions of Indians by providing financial protection against high medical expenses, especially for the economically weaker sections.
Read more about the government health insurance schemes in India to know more in detail.

 

Types of Health Insurance Coverage

• Hospitalization Costs

Expenses incurred during hospital stays, including room rent and doctor fees.

• Day Care Procedures

Treatments that do not require a full 24-hour hospitalization.

• Organ Donor Expenses

Costs related to organ transplants.

• Ambulance Charges

Fees for ambulance services.

• Maternity Expenses

Costs associated with childbirth and related care.

• AYUSH Health Treatments

It provides coverage for substitute treatments like Ayurveda, Yoga, Unani, Siddha, and Homeopathy.

 

Health Insurance Renewal Process

• Review Your Policy

Before Health insurance renewal, check the policy details to ensure it still meets your needs.

• Premium Payment

Pay the Health Insurance renewal premium before the policy expires to avoid a lapse in coverage.

• Update Information

If there are any changes in your health or personal details, update them during renewal.

• Receive Confirmation

Once the premium is paid, you’ll receive a confirmation of renewal and your policy will continue with the updated terms.

 

Health Insurance Claims Process

Making a Health Insurance claim with health insurance in India involves these steps:

• Inform the Insurer

Notify your insurance company about the hospitalization or treatment as soon as possible.

• Collect Documents

Gather required documents such as hospital bills, discharge summaries, and medical reports.

• Submit Claims

For cashless treatment, present your insurance card at a network hospital. For reimbursement, submit the documents to the insurer along with a completed claim form.

• Claim Processing

The insurer will review the claim and verify the documents. If approved, the expenses are either directly settled with the hospital or reimbursed to you.

 

Conclusion

Health insurance is an appliance that manages medical expenses and ensures access to quality healthcare. Understanding the various government schemes, coverage options, and the claims and renewal processes can help you make informed decisions about your health insurance needs. By being aware of these aspects, you can better protect yourself and your family from unexpected medical costs and ensure a smoother experience with your health insurance provider.

Insure yourself with health insurance, compare and review government schemes like Ayushman Bharat, and assess different policies to find the right coverage for you. Don’t wait until an emergency arises—secure your health with Best Health Insurance coverage today with us.

 

FAQs

Q1. What are the benefits of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana?

Ans: Ayushman Bharat provides up to ₹5 lakhs of coverage per family per year for hospitalizations, including surgeries and treatments, helping low-income families access quality healthcare.

Q2. How can I check if I am eligible for government health insurance schemes?

Ans: Eligibility criteria vary by scheme. You can visit the official websites or contact local government offices to find out if you qualify.

Q3. What should I do if my health insurance policy is about to expire?

Ans: Review your policy, make the renewal payment on time, and update any personal or health information to ensure continuous coverage.

Q4. How do I file a claim for hospitalization expenses?

Ans: Inform your insurer, collect and submit necessary documents, and either present your insurance card at a network hospital for cashless treatment or file for reimbursement with the insurer.

Q5. What are common exclusions in health insurance policies?

Ans: Common exclusions may include pre-existing conditions during the waiting period, cosmetic surgeries, and treatments for certain diseases not covered under the policy.

Q6. Can I add family members to my existing health insurance policy?

Ans: Yes, most policies allow you to add family members. Check with your insurer for details on coverage and premium adjustments.

Q7. How does the no-claim bonus work?

Ans: A no-claim bonus rewards policyholders for not making any claims during a policy year, often increasing the sum insured or reducing the premium for the next year.

Q8. What documents are needed for a health insurance claim?

Ans: Typically, you’ll need hospital bills, discharge summaries, medical reports, and a completed claim form.