As someone who has purchased health insurance for the peace of mind and protection that it accords, you should be aware of the rights that you have vis-à-vis your insurance service provider. Health insurance portability is the right of insurance policy holder to choose a different health insurance service provider and to transfer the accrued credits of an existing policy to a new one. In other words, if one health insurance provider’s service should in anyway be deficient or if another service provider offers better care, the insured person is free to port their policy as they deem fit.
For several years now, it has been possible for health insurance policy owners in India to port their health insurance to a different service provider. There are difficulties and limitations here, since an insurance company would naturally be interested in retaining existing customers and preventing them from opting for a different service provider. Moving from one to another insurer is still difficult, particularly for people with preexisting conditions or for older customers. We look at the rules regarding portability and the difficulties that still exist.
Who can port their health insurance policy and when?
Anyone can port their policy for any number of reasons. The most typical reasons include:
- Insurance companies come out with better, more attractive products from time to time. For instance, a newer product may have no cap on hospital room rent whereas the older policy may, and may offer free yearly health checkups and similar attractive features.
- There could be wider inclusions, better facilities or more extensive hospital networks offered along with such newer products.
- Newer products may also be more suitable for people with specific health issues; the old policy may be lacking in this sense.
- In the case of one company providing poor service, unsatisfactory or delayed claim redressal as well, the policyholder may choose to look elsewhere for their health insurance needs.
- One's existing insurance policy could have hidden terms and conditions and may not be transparent in the way it deals with customers.
Policyholders could be unsatisfied with their policy or policy provider for these and other reasons. In any such case, one is free to opt for such newer, improved insurance products and the policyholder is free to take their business elsewhere. Where earlier one would hesitate to change their service provider because of the apprehension of losing the benefits accrued on their policy, since October 2011, health insurance portability has accorded extra protections to the consumer.
Know your rights as a policyholder
- According to experts, portability is good for all concerned and that it would lead to policyholders being able to enjoy better products and services. Industry insiders also feel that this leads to overall improvement in customer service levels and promotes innovation and improved delivery mechanisms. Portability would ensure that healthy competition in the market for customer retention would lead to better value for money products and better service.
- According to the IRDA’s consumer education website, health insurance policyholders can shift their policy from a general insurance company to a specialized health insurance company. Both family and individual policies are permitted to be ported. The new insurance provider is bound to offer insurance cover to the extent of the sum assured under the previous policy and is liable to give the purchaser credit accrued via the previous policy.
- Hence, the policyholder does not lose the benefit of the waiting period for covering "Pre-existing Diseases" or any bonus that may have accrued by virtue of making the change to another service provider. The two insurance companies are bound to complete porting as prescribed by the regulations and guidelines issued by the IRDA for the protection of the policy holder’s interests.
- According to the circular from the competent authority on health insurance portability, the insurance company is required to respond to and acknowledge portability applications within three working days of their receipt.
Health insurance portability conditions
The health insurance policyholder is free to port their policy upon renewal and not during pendency of the policy. If the policy is for the duration of one year, as health policies usually are, the policyholder can purchase a new policy from a new service provider at the juncture of renewal.
All the benefits of the old policy would carry over to the new policy provided the previous policy is maintained without break. Not paying premiums on time and delaying renewal beyond the 30-day grace period (which is permitted when the policyholder opts for porting) would constitute such a break. There could be certain terms and conditions applicable to the new policy which the customer should familiarize themselves with.
The policyholder has to inform the existing insurance provider of the intended shift 45 days before the policy is due for renewal. The policyholder has to inform the existing insurer which company they will be porting their policy to.
Common problems with health insurance portability
While healthy, younger policyholders typically have few to no problems with portability; it is more difficult for people with diseases
or those above the age of 45. In the latter case, the policyholder may have to undergo medical checkups or answer lengthy questionnaires about their health. This is reasonable because it increases the new insurer’s liability and the possibility of the policyholder making a claim.
For this reason, the new insurer will undertake thorough investigation before permitting portability. Conditions such as an additional waiting period or specific exclusions maybe imposed and in some cases, there could a rejection of the proposal for porting. Much will depend upon the present health condition of those insured, the severity of the illness and their claims history. Though in theory, the bonuses earned by a policyholder vide his older policy will carry on to the new policy, there could be limitations to this as well. There may also be cases when the bonus carried over to the new policy becomes chargeable.
In conclusion, policyholders have to remember that the ability to portability one’s health insurance is an important right conferred upon insurance policy buyers. However, the right is not absolute and is subject to certain limitations and conditions that service providers may impose.
Health Insurance Claims procedure
It is easy to buy health insurance online. There are many attractive looking offers and blandishments offered by insurance companies keen to sell policies. Before you buy a policy, the company sales rep will call you repeatedly, answer all questions and be approachable. However, as any insurance policy holder knows, the claims process is an altogether different matter. We look at the procedure you would need to follow to make a health insurance claim to that you encounter the least amount of hindrance when you make a claim.
A valid claim under a current policy
The first thing that a policyholder has to check is that the claim being made is under a valid and current policy. The claim has to be made only for treatment undergone during the period of the year (or two years as the case may be) for which the policy is valid. If a claim event falls within two Policy periods (i.e. treatment is still on when one policy period ends and another begins) it will still be a valid claim so long as the insurance premium is paid on time.
The claim should be related to covered ailments and diseases and should not arise out of any of the exclusions that are listed in the health insurance policy terms and conditions.
Intimation to insurance company for cashless claims
When a cashless claim is to be made, it can only be made with respect to treatment at a network hospital. It is therefore advisable for the policy holder to check the list of hospitals and diagnostic centers that the insurance company partners with to provide cashless services beforehand so that they are familiar with such medical facilities in the area and know where to go when illness or emergency strikes.
The list of network providers is typically available on the website of the insurance company. It is also advisable to read the insurance policy as well as the terms and conditions relating to claims
thoroughly so when an unfortunate event occurs giving rise to a claim, you know exactly what to do.
Before checking into a network hospital or medical facility or taking any treatment there, the policyholder has to get in touch with the insurance company’s In House Claims Processing Team. For this as well, it is advisable to have all the relevant phone numbers and other information at hand. It may be a good idea to feed in the health insurance company’s toll free numbers into your mobile phone's phone book and to have details about the policy, its number and other details stored in your phone for ready referral at any time. This can come in very handy in case of an emergency.
The policy holder has to give particulars such as the policy number, the name of the patient as well as their relationship to the policy holder, the type of illness or injury, location or patient, the name of the hospital or medical practitioner and all other relevant information to the claims processing team representative. This is known as pre-authorization, which is typically required to be done within 24 hours of hospitalization in an emergency. In the event of a planned or scheduled hospital procedure, the pre-authorization should be done in advance. Usually, companies need the policyholder to inform them of such scheduled hospitalization at least 48 hours in advance of hospital check in.
Procedure in case of reimbursement claims
For a reimbursement claim (other than cashless claim), all the relevant information about the policy, policy holder and treatment should be relayed to the insurance company within a time as may be specified by the terms and conditions of the policy (usually 10 days or less from initial hospitalization). Since is this not a cashless service, the policy holder has to make all payments to the hospital and other medical practitioners and then claim reimbursement for those under their health insurance policy. Hence, the policyholder must make all requisite payments in full upon checkout. The policyholder must also ensure that reasonable care is taken to minimize the medical expenses incurred at the hospital. If the insurance company has reason to believe that expenses were inflated, this could be grounds for dishonoring a claim.
All original documents relating to the check-in to hospital, treatment, consultations, diagnostic tests, surgery, prescriptions, case papers, referral letters and checkout documents are required to be submitted to the insurance company. Original documents have to be submitted so that the policyholder doesn’t try to make more than one claim for the same treatment. In some cases, the patient may be asked to undergo a medical examination by the company nominated medical practitioner. This could be a requirement if there is some doubt as to the authenticity of billing, illness or medical condition, or about the treatment given.
Procedure to be followed at the hospital
When a policyholder approaches a hospital or medical facility listed on the insurance company network list, the policyholder should ask to be guided to the insurance desk of the hospital. There, the policyholder must offer some proof of identification and inform the hospital about the existing insurance policy under which the treatment is to be initiated. The policyholder must ideally ensure that the pre-authorization is forwarded by the hospital to the insurance company so that the requisite procedures can be initiated at the company’s end.
These are the general procedures health insurance companies expect policyholders to follow there could be variations to the procedures followed by different service providers. It is therefore very important that the policyholder read the policy and become fully familiar with the claims procedure in advance - not to wait until the last moment to do so.
List of Government Health Insurance Schemes
The good health of people and easy access to healthcare is one of the most significant indicators of well-being of a populace. As such, successive governments of India have created health related schemes to benefit various strata of society through nationalized insurance companies as well as via government programs created under the aegis of departments such as Insurance, Health, Agriculture, Rural Development, Financial Inclusion, Pension, Child Care and so on. We look at some of the government backed healthcare and insurance schemes that Indian citizens can avail:
Public sector insurance company health care
Four nationalized insurance companies that provide health insurance policies
for buyers to choose from. Several of these policies offer features that are quite similar to products from private players such as HDFC, ICICI, Max Bupa and so on.
Oriental Insurance Healthcare Products – Various healthcare policies are created for individuals, groups, seniors as well as for overseas requirements:
- Mediclaim Policy (Individual)
- Group Mediclaim Policy
- Health of Privileged Elder (HOPE)
- Happy Family Floater Policy 2015
- Overseas Mediclaim Policy (B&H)
- Overseas Mediclaim Policy (E&S)
- OBC-Oriental Bank Mediclaim Policy
- PNB-Oriental Royal Mediclaim Insurance Policy
- Pravasi Bhartiya Bima Yojana Policy
- Jan Arogya Bima Policy
- Oriental Happy Cash Policy
All particulars of the policies are available on the insurance company website. The policy document including the terms and conditions of the policy, the prospectus and other information connected to the respective policies can be accessed to read and to print as that policy buyers can read all particulars before making a purchase.
The New India Assurance Company Limited –
Apart from other insurance products like householder's policy, motor insurance products, shopkeeper's policy and fire & machinery policies, the government owned company also offers health insurance. The Mediclaim policy offers protection for unforeseen hospitalization expenses subject to standard exclusions. The policy covers treatments in India and compensation is offered for healthcare facilities located applicable zones (as specified) of that policyholder.
The company also offers the Overseas Mediclaim policy which is designed with frequent corporate travelers in mind and covers expenses incurred towards illness, injury or other treatments required when aboard. Premiums are payable in Indian currency and claims can be settled in foreign currency abroad. Various sector plans are available.
"United India Insurance Company Ltd. –
Presenting an array of insurance products, this public sector company also offers health insurance policies for individuals and families. People with preexisting conditions, disability or deformity are required to visit the nearest office, while others can buy their health insurance policy online by choosing policy period, type of policy and other details. Buyers can choose between family floater cover and individual family cover, choose the policy amount (between Rs 2 and 10 Lakhs) and indicate whether daily cash allowance and ambulance compensation is required to get an instant quote.
National Insurance Company Ltd –
Anyone between the ages of 18 and 65 can apply for one or two year health insurance policies. Policy options include the National Vairishtha Mediclaim policy for Senior Citizens, Critical Illness cover, Family Floater plans such as the Parivar Mediclaim policy, individual policies and group Mediclaim policies.
Other national health programs and insurance schemes
Apart from health insurance products that are offered via public sector /government owned companies that offer products quite similar to private insurance companies; there are other government schemes that offer health protection to Indian citizens.
Rashtiya Swasthiya Bima Yojana (RSBY) –
This scheme is for the benefit of people below poverty line. This program from Ministry of Labour and Employment, is meant to provide poor families health care for any conditions that require hospitalization. There is no age limit and preexisting conditions are covered for a family of up to five people (spouses plus up to three children). Treatment is available at government hospitals as well as private hospitals across India; at centers that are empanelled under the RSBY scheme. Rs 30 by way of registration fees, is required to be paid to avail the benefit of the scheme.
Employment State Insurance Scheme (ESIS) –
Designed as a social security system for workers and their families, this scheme provides protection for workers who fall ill, suffer permanent disability and loss of earning. The policy is meant to protect workers against hazardous occupations and work related injuries and is applicable to non-seasonal factories that employ ten or more people. Factories, hotels, shops, cinemas, transport undertakings and newspaper establishments as well as certain educational institutions and private medical facilities fall within the ambit of this scheme.
Central Government Health Scheme (CGHS) – This scheme is designed for central government employees as well as pensioners and is operational in major cities across India. Comprehensive health care
is provided to beneficiaries through allopathic CGHS dispensaries and wellness centers as well as polyclinics that provide alternative or complementary treatments under homeopathy, ayurveda, unani and other systems. X ray and lab exams, hospitalization are also covered under the scheme.
Aam Aadmi Bima Yojana (AABY) –
This scheme is designed with rural landless laborers in mind. The scheme offers compensation in case of death under natural circumstances or due to accident, for permanent disability or partial permanent disability. Free add on benefit to children in the form of scholarships is also available under the program.
Janashree Bima Yojana (JBY) –
Under this scheme, 45 identified occupational groups are covered. Beedi workers, carpenters, power look workers, textile workers, cobblers, fishermen, people engaged in food manufacturing, handicraft artisans, weavers, tailors, agriculturists, rickshaw workers, milk producers, forest workers, toddy tappers and many others are covered.
Universal Health Insurance Scheme (UHIS) –
This is another scheme meant for families below poverty line and is designed to reimburse medical expenses for the entire family as well as cover for accident of the earning head of the family. This is a subsidized scheme is implemented by the four nationalized insurance companies listed above and is meant to help poor family access health care. Families of up to seven members can utilize the benefits under the program.
While individuals can buy health insurance for their families and dependent seniors from any of the nationalized company products listed above, manufacturers and business owners can familiarize themselves with the government health insurance schemes offered by various state and health departments that would help protect their employees, their health and that of their families.
Difference between Medicalim and Health Insurance
Insurance is a subject that most of us find confusing; the terms health insurance and mediclaim can be especially confusing. The conditions of each policy, the terms used in those policies can be difficult to understand as well. When it comes to health insurance, these terms and conditions are especially important to understand so that as a policyholder, there are no unwanted shocks when it is time to make a claim under the policy.
Are mediclaim and health insurance the same thing?
The terms mediclaim and health insurance are more or less synonymous as understood in common parlance. Health insurance policies and mediclaim policies also offer practically the same tax deductions and benefits to policy holders. Mediclaim and health insurance are also similar in that they both offer cashless as well as reimbursement facilities. In fact, many people use the two terms interchangeably; however it is important to understand the specificity of each term:
What is Mediclaim?
‘Mediclaim’ is a portmanteau of the words ‘medical’ and ‘claim’ and the term is often used as a brand or product name in India as well as aboard. Sometimes the word is used to indicate government programs relating to health insurance. For instance, the government owned insurance company; New India Assurance offers health insurance products called Family Floater Mediclaim Policy, the Janata Mediclaim policy and so on.
According to the website of HDFC Life
, one of India's most trusted insurance providers, the term Mediclaim refers to one limited type of health insurance which offers some features of health insurance. According to the explanation offered, mediclaim policies cover some but not all expenses of health care and would typically pay for hospitalization and treatment towards accident and pre-specified illnesses for a specific sum up to an assured limit.
What is health insurance?
As most commonly understood, health insurance is more of an umbrella term used to describe all types of medical related insurance and reimbursements by an insurance provider including mediclaim policies. While mediclaim could be limited in nature, health insurance policies could be of various different types and offer additional features. Depending upon the type of policy, it could offer cover for critical illnesses, outpatient or day care procedures and features such as discount on premium, possible premium reduction or reduction of sum assured as well.
Common terms used by mediclaim and health insurance policies and what they mean
The Insurance Regulatory & Development Authority (IRDA) of India frames laws and regulations regarding the functioning of the insurance sector in India. This is to ensure that policyholders are protected and functioning is standardized so that the consumer knows their rights and what to expect from insurance providers. The IRDA also issues circulars from time to time, to make certain clarifications and issue guidelines, such as the Guidelines on Standardization in Health Insurance
which provides definitions of terms that are commonly used in both health insurance as well as mediclaim:
defined as a sudden, unforeseen and involuntary event caused by external and visible means
. In insurance terms this could refer to falls, vehicular accidents and other accidental injuries.
When buying a health insurance policy, the policyholder has to know about the concept of co-payment that requires some part of the expenses incurred to be borne by them, while the insurance company pays the rest. Co-payment is defined as cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible costs
Day care treatment –
Usually, health insurance claims become payable only in the event of hospitalizations; more particularly hospital stays of at least 24 hours. However, there are many health policies that also pay for procedures that do not require such hospitalization. These are known as ‘day care procedures’ and are defined as medical treatment, and/or surgical procedure which is undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because o f technological advancement
. In other words, this refers to procedures that would earlier have required hospitalization but don’t now because of medical advancements. For instance laparoscopic procedures have replaced many open surgeries now and minimally invasive treatments now no longer require long hospital stays.
Grace Period –
Insurance companies require prompt renewal of health care policies for the policyholder to get certain benefits and provide ongoing protection to the policyholder. Hence the policyholder is required to renew their policy as soon as it is due to lapse (one or two years from the start of the policy depending upon the type of policy opted for). Companies do provide some grace period, which is defined as specified time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage o f preexisting diseases
. The regulations specify that the policyholder is not entitled to coverage for the period for which no premium is received.
Hospital & Medical Practitioner
– These terms cannot be used loosely. A hospital has to meet certain criteria: having at least 10 beds, with qualified round the clock nursing staff and medical practitioner, fully equipped operating theatre, etc. A medical practitioner has to be registered with any Indian state medical council and licensed to practice as such. Insurance companies may also stipulate that such a practitioner shouldn’t be the policyholder’s close family member.
Medically necessary –
The treatments, medications and hospital stays should be necessary for the type of injury of illness in respect of which a claim is made. They should be prescribed and should conform to professional standards. In other words, the policyholder cannot opt for unnecessary or extra procedures and then expect the insurance company to pay for them.
Pre-existing disease –
This is excluded or requires a waiting period before any claim can be made and is defined as any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/ or were diagnosed, and /or received medical advice/ treatment within 48 months to prior to the first policy issued by the insurer
Critical illness –
Unless specifically included in the health policy, purchased separately or as an add-on, critical illnesses are not covered by a general health policy. Annexure II of the regulations lists and describes critical illnesses in detail; all inclusions and exclusions are also specified. They include
- Cancer of a specified severity
- First heart attack of specified severity
- Open Chest CABG (coronary artery bypass graft)
- Open heart replacement or repair of heart valves
- Coma or specified severity
- Kidney failure requiring regular dialysis
- Stroke resulting in permanent symptoms
- Major organ or bone marrow transplant
- Permanent paralysis of the limbs
- Motor neuron disease with permanent symptoms
- Multiple Sclerosis with persisting symptoms
Getting accurate and proper information is the first step towards buying health insurance to protect your health; to being an informed, responsible consumer.