What is Arogya Sanjeevani Health Insurance Policy?

Ashok, 28 years old, had a first-hand experience of how expensive medical treatments can become owing to his unfortunate COVID-19 hospitalization. Financially speaking, post the health scare, he came out as a completely transformed individual. He was determined to opt for a health insurance policy that would offer him the much-needed financial cushioning to meet any and all medical treatment expenses. However, when he takes a virtual stroll into the insurance market, he is, for lack of better words, “confused” -

1. Which insurance provider should he opt for?
2. How to determine which premium is worth the coverage being offered?
3. What kind of features and benefits should he be looking for?
4. Now that he is hale and hearty, should he postpone his policy purchase for a few years and put the premium to prioritized requirements?

Well, the first question to answer is - he should absolutely be taking a health insurance plan during his young and healthy-as-a-horse days. That’s because he will be looking at lower premiums and conveniently covering waiting periods before his health complications kick in.

As for the rest, these are one of the most frequent doubts in the mind of potential policyholders. As a result, one usually either postpones their policy purchase or opts for a plan that isn’t exactly one of the best health insurance policies available in the market.

To resolve these two-fold issues, IRDAI (Insurance Regulatory and Development Authority) mandated the inclusion of the Arogya Sanjeevani Health Insurance Policy, which comes with transparent policy terms and conditions, adequately appreciable perks and benefits, affordable premiums, and more.

While this initiative is a welcome notion from the insurance regulatory body, how effective is this for you? Does it tick the boxes on the checklist for a good health insurance plan? What are its eligibility criteria, features, perks, and difference from a standard health insurance plan?

Since it will be your financial responsibility to bear, it is logical that you know all about this in detail.

What is Arogya Sanjeevani Health Insurance Policy?

Arogya Sanjeevani Health Insurance Policy is a standardized plan introduced and mandated by the IRDAI to

• Simplify health insurance policy for potential policyholders
• Increase transparency between the insurer and the insured.
• Boost insurance penetration across the nation by increasing accessibility to such plans.

The plan is similar across all insurance providers - 30 general and standalone health insurers (with a slight tweak in its features and perks). It is a means for potential policyholders to bypass the obstacles raised by expensive premiums and illegible guidelines. Despite being so affordable and simple to understand, the IRDAI ensures that the features under the Arogya Sanjeevani Health Insurance plan are manifold and extremely appealing -

What are the Features of Arogya Sanjeevani Health Insurance Policy?

Coverage offered

As per the latest updates from IRDAI and the circular released on March 2021, the coverage under the Arogya Sanjeevani Policy is -

• Minimum: INR 50,000
• Maximum: INR 10,00,000

Needless to say, the coverage is adequate considering the cost-effective premiums that it demands (take a look at the table below to know the premiums charged as per the age of the policyholders and the coverage availed).

Room and ICU rent benefits

• Room Rent: Under this IRDAI forwarded policy, the coverage of room rents is up to 2% of the sum insured, which is capped at INR 5000/day. Since room rent charges add up to a major share of the hospital bill, this coverage is a financial relief for policyholders.
• ICU: Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expense coverage of up to 5% of the sum insured. The ICU expenses are capped at INR 10,000/day.

Types of plans offered

The Arogya Sanjeevani Policy offers its policyholders two kinds of coverage - individual and family floater plans. This comprehensive approach of the policy allows maximum inclusion of the population under a health insurance plan that would offer them access to quality healthcare services at affordable charges.

Eligibility criteria

The Arogya Sanjeevani Health Insurance Plan was launched to envelop a vast majority of the nation under a preventive health plan. Keeping this in mind, the IRDAI offers an extensive range when it comes to the age of the policyholders -

[PLEASE NOTE: In the case of a family floater plan, if your child/dependent is older than 25 years, he/she will need an Individual plan since they can’t continue under the family floater policy].

Ambulance charge

Ambulance charge coverage is offered and is capped at INR 2000/hospitalization.

Pre- and post-hospitalization expense coverage

The Arogya Sanjeevani Plan offers to fund pre- and post-hospitalization coverage for 30 and 60 days, respectively. As to the kind of medical aid that is funded during this span, it differs from one insurer to the other. Therefore, the best way would be to enquire your insurer regarding the disclosure of the complete details of this feature.

COVID-19 treatment coverage

The out-of-the-blue pandemic outbreak has been one of the catalysts in pushing insurance penetration across the nation and the world at large. This was largely due to the substantial bill amount owing to the COVID treatment that piled on as a financial burden for all. Keeping this in mind, the IRDAI offers to fund COVID-19 treatment via their standardized Arogya Sanjeevani Health Insurance Plan.

Modern treatment coverage

To help a majority of the population reap the perks of modern medicine and surgical procedures, the policy offers coverage for the following new-age surgical procedures and treatments -

• Balloon Sinuplasty
• Bronchial Thermoplasty
• Intraoperative Neuromonitoring (IONM)
• Intravitreal Injections

AYUSH treatment coverage

Individuals who avail of the Arogya Sanjeevani Health Insurance Policy have access to the sum insured as coverage for the AYUSH (Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homoeopathy) treatment charges. This is specifically beneficial for those seeking an alternate mode of treatment as compared to the mainstream mode.

Additional benefits

• Cataract surgery - While the policy does offer to fund cataract operation charges, there is a cap on the fund provided - 25% of the sum insured or INR 40000, whichever is lower.
• No-Claim bonus - If an individual raises no claim across an entire insurance year, the insurer offers him/her a financial pat on the back via a No-Claim Bonus that helps increase the bandwidth of the coverage sans demanding a higher premium. Under the Arogya Sanjeevani Health Insurance Policy, the No-Claim Bonus starts at 5% and can go up to 50% of the sum insured.
• Dental treatment - The expenses incurred for dental treatment that has been necessitated and is a result of an ailment or an injury are covered under the Arogya Sanjeevani Plan.
• Plastic surgery treatment - In case any plastic surgery is called for due to injury or disease, the health insurance policy meets the expenditure in place.

Waiting period

Much like the policies offered by the best health insurance providers across India, the Arogya Sanjeevani Policy also carries a certain waiting period for policyholders with pre-existing and specific ailments -

• Pre-existing: 48 months, i.e., 4 years
• Specific diseases: 24 to 48 months, i.e., 2  to 4 years (variation is as per the ailment. Enquire your insurer about the specifics of the diseases and their respective waiting period).
• In general: 30 days. Since the purchase of the policy, a policyholder needs to wait for 30 days before gaining access to the funds and the respective perks. The exception is an accident (that is covered from Day 1 of the policy itself).

What are the pros and cons of Arogya Sanjeevani Health Insurance Plans?

Arogya Sanjeevani Plans are an excellent insurance product that safeguards the savings of individuals during medical treatments by offering substantial funding despite demanding a low premium. However, the plan carries some drawbacks that might raise concerns for potential policyholders before availing of the plan. This will help them make an informed financial decision.

Pros

• Transparent and easy-to-understand policy terms that ensure convenient policy purchase by one and all sans the worry of hidden terms and conditions.
• No zone pricing helps with a uniform premium calculation irrespective of the location of the potential policyholder.
• Affordable premiums that can be paid off in instalments (Half Yearly, Quarterly, or Monthly).
• COVID-19 treatment expenses are covered, which is an exceptional feature since individuals in a post-pandemic world usually seek COVID-19 covers as add-ons for their existing health insurance plan or as a standalone plan. Under such circumstances, this standard health insurance policy offers coverage for its treatment in its base plan, which is a welcome feature.
• The Cumulative Bonus option or the No-Claim Bonus option stretches from 5 to 50% of the total sum insured.
• Tax benefits under Section 80D
• Appealing choice for 1st-time health insurance policy buyers since they need not be worried about which insurer to approach, which insurance plan to avail of, which features to prioritize, and more.

Cons

• Low covearge amount: The coverage offered might fall short considering the skyrocketing cost of health treatments and medical inflation. Additionally, since no Super Top-Ups are available, increasing the coverage bandwidth capped at INR 10 lakhs is impossible.
• 5% copayment: Though the copayment is low, it still defeats the purpose of purchasing a health insurance policy (so that you don’t have to invest out of your pocket). Also, when you are billed INR 6 lakhs, the 5% comes to INR 30,000, which is undeniably a high cost to bear when you are already under financial constraints.

• No available add-ons: Since Arogya Sanjeevani Policy is a standard health insurance plan, the IRDAI doesn’t offer any add-ons on the policy. However, some of these add-ons, namely -
  • Super top-ups, increase the coverage bandwidth at low premiums.
  • Protector riders shield the policyholder from inflation, ensure coverage for consumables, and protect one’s No-Claim Bonus in the case of a small claim raised.

-if provided, add value to the existing health insurance plan and safeguard your out-of-pocket extensively.

• Disease-wise sub-limits: It is appreciable how initiatives are being taken to ensure that health insurance reaches far and wide. However, when there is a cap on the specific diseases/surgeries, often there are chances of either -
  • You compromising on your quality of treatment to safeguard your savings, or
  • You end up spending a huge chunk of your finances on paying the residual amount on the treatment/surgery after your insurer pays the pre-decided amount.

• Extensive waiting period: With most of the best health insurance plans across the market, the waiting period extends to 2-3 years. However, in this case, with Arogya Sanjeevani Health Insurance Policy, you are looking at a close to 4 years waiting period for some specific ailments. This period is too extensive and might pose a major inconvenience for the policyholders.
• Caps on room rents and ICU room coverage: Did you know there is a pro-rata-based calculation regarding room rents and the claim amount offered against your hospital bill?

So, say your room rent is capped at INR 5000/day. When you approach a hospital during an emergency, you find that the only available room is priced at INR 10,000. You can't turn away from the hospital because your priority is emergency treatment. So, here's what happens during the billing at the end of a 5-day hospitalization -

Total Bill = INR 5 lakhs, Coverage available = INR 10 lakhs

Room rent = INR 10,000 * 5 days

Room rent paid out of pocket = 50% = INR 25,000

Claim offered by the insurer = INR 2.5 lakhs (50% of the billed sum)

Since your room is double than the daily rent cap, you pay 50% of the room rent out of your pocket. However, despite having coverage of INR 10 lakhs, the insurer agrees to pay only 50% of the claimed amount. This is because of the pro-rata rule-based calculation, which says that if you exceed the room rent capping,

The % of room rent that you pay individually = The % of the hospital bill that you pay out of your pocket (despite having no copayment feature in your policy).

And that is how important it is to choose a plan with no room rent restrictions.

• Unavailable for senior citizens (above 65 years of age): While Arogya Sanjeevani Health Insurance Policy covers an extensive range of individuals, that they do not extend their plan to senior citizens is a significant drawback. However, for those above 65, some senior citizen health insurance plans can cater to their medical requirements.
• No domiciliary coverage: This is an important feature considering the benefits it offers of being treated from the comfort of one’s home in case a patient cannot shift to the hospital or there are no beds available.

Post this discussion on the pros and cons of this standard health insurance policy offered by the IRDAI, here is a look at some of the best health insurance providers who have included this in their product queue. These policies are effective and budget-friendly.

What are some of the best Arogya Sanjeevani Health Insurance plans in 2024?

What is the difference between a normal Health Insurance Policy and the Arogya Sanjeevani Health Insurance Plan?

FREQUENTLY ASKED QUESTIONS

1. Can NRIs avail of Arogya Sanjeevani Health Insurance Plan?

Yes,  NRIs can avail of Arogya Sanjeevani Health Insurance Plans, provided -

• They are in India during the policy purchase.
• Pay the policy premium over Indian currency.
• Utilize an Indian bank account for the premium payment.

2.  What is the tenure of the Arogya Sanjeevani Policy?

The tenure of the Arogya Sanjeevani Health Insurance Plan is for a year and is available for lifelong renewal.

3.  What are the eligibility criteria of the plan proposer in the Arogya Sanjeevani Health Insurance Plan?

The only eligibility criteria of the plan proposer in the Arogya Sanjeevani Health Insurance Plan is - he/she has to be between 18 and 65 years of age. Accordingly, he can purchase the Arogya Sanjeevani Policy for himself/herself, the spouse, and the dependent children (who must be between 3 months and 25 years old).

4.  What are the types of Plans Arogya Sanjeevani Health Insurance has?

There are no variants of the Arogya Sanjeevani Health Insurance Plan, only one with coverage ranging from INR 50,000 to INR 10 lakhs. One can purchase this policy as an Individual or a family floater plan.

5.  What is the waiting period for Arogya Sanjeevani policy?

The waiting period on the Arogya Sanjeevani policy varies based on the ailment in discussion -

1. The initial waiting period is of 30 days. Any accident-related coverage is an exception to this rule.
2. The waiting span for any pre-existing illness lasts 4 years.
3. For specific diseases, the period may vary - 2 years or 4 years.

6.  Is Arogya Sanjeevani the Ideal Health Insurance Plan for India?

While Arogya Sanjeevani Health Insurance Policy is affordable, sans any financial complications, and offers COVID-19 treatment cost coverage, it is far from being an ideal health insurance plan considering - the extensive waiting period, mandatory copayment, no domiciliary coverage, room, and ICU rent restrictions, disease-wise sub-limits, no coverage for senior citizens, no add-ons available and low coverage offered.

In short, the plan fails to meet the determining factors that help choose the best health insurance plan. However, one can still go for it if they are looking for an affordable premium.

7.  What is the claim process for Arogya Sanjeevani Policy?

The claim process for the Arogya Sanjeevani Plan is the same as for any other health insurance policy, and it can be availed in 2 ways - cashless (in the case of a network hospital) and reimbursement (in the case of a non-network hospital).