What does health insurance cover?

Coverage is probably one of the first questions that come to mind while talking about a health insurance policy. Since not all policies cover every health condition and some policies have a cap for certain facilities, it is important to know what you are paying for.

In this article, we will explore some of the things that health policies cover. Make sure you compare various policies and read the policy documents before choosing one for you and your family.

  1. Health insurance covers medical expenses
  2. Health insurance covers COVID-19 treatment
  3. Health insurance covers critical illness
  4. Health insurance covers cashless claim benefit
  5. Health insurance covers hospital cash
  6. Other facilities covered by health insurance companies
  7. Things to consider before buying health insurance

A health insurance plan covers your medical bills in case of an emergency. It not only helps you avoid big expenses but also makes sure that you get the best possible treatment. myUpchar insurance plus health insurance covers hospitalization charges, pre and post hospitalization expenses, household expenses, ambulance charges, cashless facility, daycare procedure (in case hospitalization is required for less than 24 hours, the term day-care is used), etc. These facilities are generally covered in all health insurance policies. Let us have a look at some of the medical expenses a health insurance policy may cover for you:

Daycare: Daycare is a term used for treatments that require hospitalization for less than 24 hours. If your medical condition is less severe, say if it can be cured in a day or two without the need for hospitalisation, it will come under OPD, which health insurance usually does not cover. 

Annual check-up: An annual health check-up helps your doctor monitor your medical condition and suggest preventive measures or lifestyle changes if and when required. For people who are at risk of certain diseases, it aids in timely diagnosis and early treatment, if the need ever arises. 

Second opinion: In India, people usually become so comfortable with their doctors that sometimes they don't even consider a second opinion. We often forget that two doctors can have different views. Therefore, getting a second opinion can give you more information about your situation, which, in turn, can help you take the next step. 

Organ donor cover: If the policyholder needs an organ transplant, the policy may cover the medical and surgical expenses of the organ donor to ensure that the insured gets the organ that he/she needs on time.

Hospital expenses: If a person has taken health insurance and needs to be hospitalized for more than 24 hours, then the insurance company will bear the cost as per the prescribed terms and conditions. However, the percentage of expenses varies from policy to policy. Apart from this, ICU expenses are also covered in this. 

Pre and post hospitalisation: The expenses from the indication of an illness to post-treatment are covered under 'Pre and Post Hospitalization cover. This includes consultation with a doctor, diagnosis of illness, hospitalization and medical expenses up to a few days after discharge from the hospital.

As per most of the health insurance policies, 30 days before hospitalization and 60 days after discharge from the hospital are included in pre and post-hospitalization. Nowadays, some health insurance companies cover the expenses related to the illness up to 60 days before admission and 120 days after discharge. 

Ambulance fee: Emergency services often cost a lot. Hence, it can be a wise decision to opt for health insurance policies along with road or air ambulance in case of an emergency. There are many health insurances available in the market that cover the cost of such services. Although your normal health insurance policy also covers ambulance fees up to Rs 1500 or Rs 2000, air ambulances are generally not covered. myUpchar Bima Plus insurance provides medical cover of up to Rs 1500 for ambulance fee. The condition in this is that the claim can be made only from the place of emergency to the nearest hospital.    

Automatic recharge: Automatic recharge or auto-refill policy always looks attractive. Insurance agents rave about its benefits so much that customers tend to forget some important things. In an auto-refill policy, an amount equal to the Sum Insured of your policy is refilled in the same policy year. However, auto refill policy terms are not the same in every company. Here are some points which you need to understand: Some companies offer auto-recharge facilities only after you have completely used the first sum-insured.

  1. Some companies provide the facility of auto-recharge in the second or any subsequent claim even after you have spent only a part of the sum insured. For example, if your sum insured is Rs 5 lakh and you have made a claim of Rs 10 thousand, then in the second claim, if your hospital bill comes up to 9 lakh 90 thousand, your insurance company may cover it. 

  2. If a bill equal to the double sum insured comes on the first hospitalization after the refill, the company will not cover all the expenses. For example, if you have a policy of rupees 5 lakhs and the first time you get hospitalised you get a bill of about 8 lakhs, the insurance company will only provide you with 5 lakhs. If, however, you get a bill of rupees 4 lakhs on the first hospitalisation and then another 4 lakhs later in the year due to hospitalisation for another health condition, then you will be benefited by auto-refill. 

Given the current pandemic, it is normal to be concerned whether your health policy will cover your medical bills in case you or a family member acquires COVID-19. You might be relieved to know that most health policies do cover COVID-19 treatment. Not only this, in view of the pandemic, some insurance companies are also covering corona vaccination. myUpchar Bima Plus Health Insurance not only covers the treatment of corona but also provides 24x7 free online consultation to patients.

Extended hospitalisation cover: Viral diseases like COVID-19 may require the patient to be hospitalised for a few days or weeks. In such an emergency situation, one can avoid hefty medical bills with the help of an Extended Hospitalization Cover. 

Vaccination cover: Generally, health insurance companies do not cover vaccination, but in view of the rapidly rising corona cases, many health insurance companies are now offering cover for vaccination too. In fact, some health insurance companies have designed separate policies for this, aimed at hospitalization expenses, pre-hospitalization and post-hospitalization expenses and other medical expenses associated with COVID-19. Since COVID-19 is a new disease, it does not fall under the category of pre-existing diseases. 

Follow up tests: Most patients are considered free from the COVID-19 virus only if their COVID test results are negative. In such a case, follow-up tests are required to ensure that the patient has indeed recovered.

Keep in mind, the follow-up test includes only those tests, which are asked to be done by the network hospital. Apart from this, only tests related to the prescribed disease or medical condition for which you go to the network hospital will come under health insurance.

If a medical condition is covered by your insurance company, then it may help you with a lump sum amount on diagnosis of the disease. This money can be used to meet the expenses related to illness, daily expenses and other financial obligations. Make sure to read the policy wordings carefully to know which diseases your health policy covers.

Examples of serious diseases

Some examples of critical illnesses include:

Insurance companies offer cashless claim facilities in their network hospitals. In this arrangement, you do not have to pay cash or out of pocket money in case of an emergency. The hospitalization cost is decided between your insurance company and the hospital. However, to avail this facility, you need to be hospitalized within the insurance company's network hospitals. 

To avail the cashless facility, you need to fill up a pre-authorization form and show your health insurance card at the counter. If you are not admitted in an emergency and are planning any surgery in advance, then it is necessary to take authorization from the company 2-3 days before the hospitalization. 

If your policy bond includes a Hospital Cash Plan, your health insurance company will provide you with a fixed amount on a daily basis in case you get hospitalised. This amount can be used to cover the extra hospital expenses or any other expenses you may need help with.

The competition among health insurance companies is increasing with time, everyone wants to woo the customers by giving new coverage. Health insurance also covers the following things. You can also avail additional benefits if you increase the premium amount during renewal. 

Accidents: Any general health insurance covers health-related expenses due to accidents. 

OPD cover: Even if you are not hospitalised, your insurance company may settle your health-related expenses like medicines under certain terms and conditions. For this, you have to take an additional rider of OPD cover, which will cover your OPD expenses annually up to a certain amount. 

Laser eye surgery: Generally a laser eye surgery is not covered in health insurance, but some companies also provide cover for such surgeries if they meet certain criteria. For example, some insurance companies offer 'vision plans', which cover laser eye surgery.

Maternity cover: Generally, maternity i.e. pregnancy is not covered in health insurance. But as a rider, you can take advantage of this facility. 

However, some corporations offer the benefit of maternity cover to their women employees along with a health insurance policy. It is important to note that you cannot take advantage of maternity cover as soon as you take this type of insurance. For this, some waiting period (usually 24 months i.e. two years) is fixed by health insurance companies.

If you or a family member are at risk of certain diseases, you may want to consider personal health insurance along with family health insurance. The former can provide better coverage at an affordable premium.

Also, there are many new facilities, which you can add to your existing insurance plan during renewal. However, for every such facility, a certain amount will be added to your premium amount. Make sure to consider all your needs and read and understand the terms and conditions properly before choosing a health insurance plan for yourself and your family.

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