Top 18 Questions To Ask Before Buying A Health Insurance Plan

It is important to know about inclusions and exclusions of health insurance policies before you buy one for your family. Asking these 18 questions would tell you which medical insurance policy to buy.

By Amrita Gracias  • 12 min read

Top 18 Questions To Ask Before Buying A Health Insurance Plan

Owning health insurance plans has become a necessity in the recent years. With healthcare costs increasing and medical treatments becoming frightfully expensive, buying a medical insurance policy seems like a wise decision.

Insurance companies in India nowadays sell a range of cheap health insurance plans for family and affordable health insurance plans for individuals.

However, before you buy medical insurance, you should understand well the terms and conditions, inclusions and exclusions of any health insurance policy.

Here are 18 questions that you should ask your insurance provider before you purchase a plan.

1. What are the different types of health insurance plans? 

In India, affordable health insurance plans offered by insurance companies include:

  • Mediclaim
  • Individual health insurance
  • Family health insurance
  • Senior citizen health insurance
  • Unit Linked Insurance Plan (ULIP)
  • Critical illness cover
  • Accident insurance policy
  • Hospital cash insurance
  • Top-up and super top-up health insurance

2. What is cashless insurance?

With a cashless insurance facility, the policyholder does not have to pay his hospitalisation bills. The insurance company pays the amount directly to the hospital, provided the bill is within the assured limit. Most insurance companies have a tie-up with several hospitals and the cashless insurance facility can only be availed in these hospitals. However, to limit their liability, some insurance companies include sub-limits in the policy.

3. What are sub-limits?

This refers to cap on reimbursements of certain medical expenses. For instance, your policy can have a sub-limit on the room rent, which could be 2% of the sum insured. So, if the room rent exceeds this amount, you would have to pay the remaining out of your own pocket. Sub-limits differ from one health provider to another. So, read the policy carefully.

4. What are the tax benefits for getting health insurance?

As per Section 80D of the Income Tax Act, an individual can claim tax deductions for premium paid towards health insurance plans for self, spouse, children and parents. In the case of premium paid for self or family, one can claim up to Rs 25,000 deduction. For premium paid for medical insurance for parents, who are below the age of 60 years, a deduction claim of an additional Rs 25,000 can be made. For premium paid for senior citizen parents (above the age of 60 years), a deduction of Rs 50,000 can be claimed.

5. What are the factors that affect health insurance premium?

Age is a key factor that determines the premium you pay for your health insurance plan. So, the younger you are, the lesser the annual premium. Some other factors are city of residence (cost of healthcare is higher in metros), pre-existing diseases, body mass index, and family illness. If no claims are made during a budgetary year, the policyholder becomes eligible for No Claim Bonus (NCB). NCB is a discount on the premium payable in the following year. An online tool called a Health Insurance Premium Calculator can help you determine the premium for your health plan.

6. Is my medical insurance plan valid across India?

Usually, the best health insurance plans in India from top health insurance companies are valid across a wide network of hospitals throughout the country. It is however advisable to do a double check for hospital network and locations covered by a policy.

7. What isn't covered by health insurance policy in India?

It is imperative that you check for health insurance exclusions. Here are a few things not covered by medical plans:

  • Common conditions like hernia and joint replacement surgeries (sometimes only in the initial period)
  • Dental treatment and expenses (in most cases)
  • Eye-related treatment (in some cases)
  • Cost of spectacles, contact lenses, hearing aids and dentures
  • Cosmetic surgery
  • Illness or injury as a result of substance abuse
  • Self-inflicted injuries as a result of substance abuse or mental illness
  • AIDS-related treatment and expenses
  • Congenital diseases
  • Multiple visits by the same specialist doctor in a day (during hospitalisation)
  • Certain drugs used during critical illness treatment
  • Supplementary drugs or medication

8. How long does an insurance company take for claim reimbursement?

In case, your medical plan allows for cashless facility, the claim will be made by the hospital. However, if you pay the hospital bills, you can register a claim for reimbursement with your insurance provider. Reimbursement can take up to 15–30 days. Reimbursement time depends on factors like the amount claimed, mode of request (electronic or hard copy submission of required documents) and insurer's efficiency.

9. What is meant by pre-existing diseases?

A pre-existing disease means any ailment that the policyholder already suffers from at the time of purchasing of the policy. Most insurance plans don’t cover pre-existing diseases for a certain period after purchasing a policy. However, the interval can vary between insurance companies.

10. What is a ‘health check’ facility?

Some medical plans allow individuals covered by a policy to avail a general health check-up at hospitals / clinics specified in the policy. This is called the health check facility. This option can be availed either once a year or as specified in the medical plan.

11. Can I renew my medical insurance policy after the renewal date?

If you fail to renew your medical health cover before it expires, a grace period of 15—30 days (from the date of expiry) is provided. You must pay the premium within this period. Else, the policy lapses and will not remain valid.

12. Can I transfer my policy to another insurance company without losing benefits?

Yes, you can now port your health insurance (both individual and family) plan to another company without losing out on benefits such as the waiting period for pre-existing diseases. And, the new insurer must insure you for at least the same value of your old policy. However, the porting can be done only at the time of renewal. And, you must start the process at least 45 days before your policy is due to expire.

13. What is the process for availing cashless facility at hospitals?

In case of planned hospitalisation, the policyholder must seek pre-authorisation from the insurance company. For this, a cashless claim request form together with documents required should be submitted. Once the authorisation is given, the policyholder should produce the approval letter and other documents in the hospital to seek treatment.

In the case of an emergency, you can contact the insurance help desk at the hospital. If the hospital features in the insurance company’s network, the hospital will file a claim with the company. Once approval is received and treatment given, the insurance company will pay the hospital.

14. Can I seek reimbursement if treated in a hospital not covered by my policy?

If you are admitted to a hospital that is not in the insurance company’s list of hospitals, you will have to bear all the expenses yourself. You can then claim a reimbursement from the insurer by submitting all the necessary documents. Once these are submitted, the insurance company will evaluate the claim and make the payment. In cases where the treatment is not covered under the policy, the claim will be rejected. Check your insurance provider’s claim settlement ratio to know the percentage of claims they have settled.

15. What are the documents required for filing a claim?

To file a claim, the following documents must be submitted to the insurance company:

  • Duly filled in claim forms (signed by the claimant and the hospital)
  • Discharge summary
  • Original bills and receipts
  • Investigation reports
  • Consultation papers and prescriptions
  • FIR or Medicolegal Certificate (in case of accidents)
  • A consent form signed by the claimant permitting the hospital to release any information the insurer requires for assessing the claim (usually attached to the claim form)
  • Cancelled cheque of claimant's bank account

16. How many times can I claim in a year?

You can file any number of claims in a year, provided you don't exhaust your sum insured. However, the amount of the coverage decreases with every claim. For instance, you have coverage of three lakhs, and you make a claim for one lakh; then, the coverage remaining would be only two lakhs for the rest of the year. However, nowadays, the best health insurance policies come with a built-in 'restoration benefit' feature. With this feature, your sum insured gets recharged, and you get coverage for the same amount you had opted for.

17. What is a co-payment clause?

If there is a co-payment clause in your policy, it means you have to pay a certain (small) percentage of the medical expenses on your own. For instance, if your co-payment is 20%, then you have to pay 20% of the total expenses while the insurance company will pay the remaining amount. This clause can result in lower premium. However, it can be a disadvantage, especially when expensive / life-saving medical treatment is required.

18. What is the maximum age limit for health insurance coverage?

Quite a few policies these days allow entry into a plan even for senior citizens aged between 60 and 80. Some even offer health insurance plans for super senior citizens. However, as far as renewals are concerned, while most health insurance companies offer them lifelong, some restrict them to 90 years. Therefore, to know up to what age you will be covered, it is best to check with the insurance company.

While insurance companies tell you about the benefits of their health insurance policies, there are several riders attached to every plan. So, before you buy one, make sure that you read the fine print and ask these 18 questions.

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