Human immunodeficiency virus (HIV), Ebola, COVID-19 and dengue are now household names around the world. The frequency and intensity of these diseases are becoming more common. Jeremy Farrar, director of Wellcome, a global health charity, says: “We are living through an era of epidemics and pandemics, which will become increasingly complex and frequent.”
As these outbreaks increase, so do medical costs. But the question is: Does your health insurance cover these illnesses?
The emergence of diseases such as Mpox, which the WHO has declared a public health emergency of international concern, raises concerns similar to those seen during the Covid-19 pandemic.
“The good thing is that most standard indemnity-based health insurance policies in India cover hospitalisation expenses incurred for treatment of diseases like Mpox. Indemnity policies are designed to cover a wide range of diseases, including new and emerging infectious diseases that require hospitalisation,” explains Bhaskar Nerurkar, Head, Health Management Team, Bajaj Allianz General Insurance.
Siddharth Singhal, Head of Health Insurance at Policybazaar.com, adds, “While there may not be exclusive plans just for emerging infectious diseases, all of them are generally covered under the broader umbrella of health insurance hospitalization.”
Nerurkar also mentions: “Some insurers may offer additional clauses that enhance coverage during pandemics or epidemics, but these are not disease-specific.”
So, if you have a comprehensive health insurance plan, your insurer will likely cover any hospitalization due to the Mpox virus. However, as Nerurkar advises, “It is prudent to review your policy details and check with your insurer to ensure you have comprehensive coverage for any emerging infectious disease.”
Costs covered by insurers in case of outbreaks
“Health insurance plans offer a variety of benefits, including coverage for hospitalisation expenses, daycare procedures, ambulance expenses, consumables and room rent,” says Mahesh Yelapur, Head of Medical Insurance Underwriting and Health Claims at Go Digit General Insurance. However, the details of the coverage depend on the plan chosen and its terms.
But yes, there are some out-of-pocket costs that policyholders should be aware of.
While most hospitalization expenses are covered, you may have to pay out of pocket for things like outpatient treatment or certain policy coverages. “For example, if your plan includes a co-pay clause, you may be required to pay a specific portion of the medical bill. Also, while cashless claims at in-network hospitals eliminate upfront payments, out-of-network hospitals may require you to pay upfront and then seek reimbursement,” Yelapur notes.
Common out-of-pocket costs
According to Singhal, some of the most common out-of-pocket costs include:
ConsumablesHealth insurance generally does not cover the cost of medical items and supplies used during hospitalization or treatment.
Copayment:Some plans may have a co-pay clause, which means the insured must pay a certain percentage of the claim amount.
DeductiblesA deductible is the amount the insured must pay before the insurance company begins to cover costs.
How to ensure coverage during an outbreak?
Nerurkar suggests the following steps to ensure adequate coverage during an outbreak:
1. Keep your policy activeMake sure you have an active health insurance policy that covers hospitalization, as most policies will include coverage for infectious diseases that require hospital treatment.
2. Check your coverage: Periodically review and update the sum insured based on your needs. Considering the rising costs of healthcare due to medical inflation, it is essential to choose a sufficient sum insured.
3. Consider additional passengers:Adding clauses that cover consumable items, often excluded from standard policies, can help minimize out-of-pocket expenses on items such as gloves, masks, and other necessary supplies.
4. Select a comprehensive plan: Choose a health insurance plan that includes coverage for modern treatments, as these can be essential if advanced medical procedures are needed during an outbreak.
Policy Bazaar lists a few options for a 30-year-old looking for a base cover of Rs 10 crore in Delhi:
1. Health care: benefits of care:Rs 15,479 (premium inclusive of GST)
2. Star Health – Smart Health Professional:Rs 15,515 (premium inclusive of GST)
3. Manipal Cigna – Health for Life:Rs 13,297 (premium inclusive of GST)
4. Aditya Birla Health Insurance – Activ Fit Plus: Rs 17,058 (premium price inclusive of GST)
5. Niva Bupa Health Insurance – Reassure 2.0 Platinum: Rs 24,605 (premium price inclusive of GST)
6. HDFC Ergo – Optima Secure:Rs 25,781 (premium inclusive of GST)
7. Bajaj Allianz General Insurance – My Health Care Plan:Rs 22,438 (premium inclusive of GST)
Documentation required for claims
To ensure a smooth claim process, you should have the following documents ready:
1. Original claim form, duly completed and signed.
2. Valid Identity Proof (e.g. Aadhar Card, PAN Card, Voter ID).
3. Medical prescription recommending hospitalization.
4. Medical prescription advising diagnostic tests, medications and consultations.
5. Original pharmacy invoices for medications and treatments.
6. Policy details, including policy number, name of the insured and the disease to be treated.
For cashless treatment at an in-network hospital, you will need to provide a claim pre-authorization form and a valid photo ID. The hospital will be responsible for sending the necessary documents to your insurer.
Instead, to claim reimbursement, you will need to gather and submit all relevant documents, including medical bills, from the hospital where you received treatment. Once the insurance company verifies the submitted documents, the claim amount will be transferred to your bank account.
What should you consider when choosing a health insurance plan?
Singhal suggests the following points when choosing a health insurance plan that covers emerging diseases:
1. High sum insured:These diseases can lead to costly medical treatments, so it is worth ensuring that you have a plan with a high sum insured. For metropolitan cities, a minimum cover of Rs 10 crore is recommended.
2. Purchase in advance: Purchase insurance as soon as possible, as there is usually a waiting period associated with most conditions.
3. Add-ons:Consider purchasing add-ons as consumables to reduce out-of-pocket expenses.
4. No limit on room rentals:Opt for an unlimited room rental plan to ensure comfort during treatment.
5. OPD Coverage: Consider purchasing OPD coverage as some conditions may not require hospitalization but will still incur costs for doctor visits, medications and diagnosis.
Nerurkar warns that certain preventive measures may affect your coverage, including:
Travel restrictions: Traveling to areas with government-issued travel restrictions due to health risks could affect your coverage.
Regular health checkupsInsurers encourage regular health checks, which can lead to lower premiums or discounts.
VaccinesStaying up to date on recommended vaccinations can impact coverage, especially for diseases like influenza or hepatitis.
Lifestyle ChoicesHealthy lifestyle practices, such as regular exercise and a balanced diet, can have a positive impact on your coverage, often resulting in lower premiums or additional benefits.
How are insurers adapting to the growing number of outbreaks?
“Insurers are enhancing their standard health insurance offerings to ensure better coverage and flexibility,” says Nerurkar. They are improving claims processes by incorporating digital tools and AI-powered technologies, ensuring timely support to policyholders, especially during periods of high demand.
Recently, the Insurance Regulatory and Development Authority of India (Irdai) mandated that all cashless claims be processed within three hours of receiving a request for discharge clearance from the hospital. Insurers are also gradually adopting the National Health Claims Exchange (NHCX) platform, which promises faster and easier claim settlements.
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