Introduction

Alisha, a 28-year-old, is ecstatic. She just received a confirmation from a renowned MNC and her date of joining is a week from now. After a deserving pat on the back from herself and her family, she receives an email from the HR team of the said enterprise - a PDF of a policy that requires

  • A few document submissions,
  • Agreement with the NDA (Non-Disclosure Agreement) as put forth,
  • Notice period,
  • Some medical details that would help in deciding her health insurance plan premium offered by the company,
  • Restrictions on moonlighting and
  • A few more personal and professional details.

She sits down to fill it up online, with a smile on her face knowing the perks that the company is bringing to her.

Whether we are talking about a real estate deal, hiring in an enterprise, or a cultural event - such policy documents are part and parcel of each industry and an individual’s induction into the industry. The health insurance sector is no different.

However, with health insurance policy documents, the financial implications run deep, making it a crucial document that one needs to be very well-acquainted with before one signs these documents. After all, health insurance policy documents are a prologue to the financial security blanket offered by the best health insurance providers during medical emergencies.

However, to ensure that your health insurance policy runs smoothly and is there as your financial BFF during medical happenstances to defend your “Scrooge’s gold pit”, a.k.a, savings, it’s vital that you know what a health insurance policy is, what are its hurdles, and what exactly are those minute details that you need to focus on once you have your hands on the policy doc.

Considering how finely the insurers write those fine prints on the policy doc, you need some expert assistance. Let’s help you out!

What is a Health Insurance Policy Document - Importance, Hurdles & More!

A health insurance policy document is a legal contract between the health insurer and the insured individual that acts as proof of the insurance availed and comprises diverse features, details on any health insurance add-on availed, personal details of the insured, the nominee, and the insurer, along with premium and its complete breakdown, pre-existing medical conditions if any and its concurrent loading charges, etc.

This policy document is largely based on the premium that a policyholder wants to pay, the variant that he/she has chosen, and the policy proposal put forward. This doc is drawn and jotted down by the health insurance underwriting team of the insurer in question.

A. IMPORTANCE OF HEALTH INSURANCE POLICY DOCUMENTS:

Considering that the health insurance policy document is a legal contract, it is a safety shield for both the insurer and the policyholder since neither can negate the coverage, the features, permanent exclusions, waiting period, add-ons, terms and conditions, and the sum insured offered.

Hence, the policyholder is guarded against any two-faced situations during the times when they need to bank on their funding, and the insurer is financially protected against any baseless cases raised against them in the name of a verbal promise.

B. HURDLES:

While a health insurance policy document being a legal contract is a safety cushion for both parties, unfortunately, for policyholders, the very same perk becomes a major hurdle.

Skimming through a document bombarded with legal, financial, and medical jargon is no easy feat. And yet, a necessity because availing of a health insurance plan is a substantial financial decision that requires a well-informed approach.

Now, a health insurance glossary can truly help with a majority of the terms in the policy document, so will approaching health insurance experts, and acknowledging a few of the crucial pointers that you need to check in your health insurance policy document.

Things To Check in a Health Insurance Policy Document

  1. Accuracy of the Proposer & Insurer’s Details

Whether you are dealing with an individual or group, or family health insurance plan, the first thing that you need to check in a health insurance policy document is the personal details of the policyholder, insurer and nominee. The address, contact number, and names need to be accurate so that during claim settlement, there is no confusion, and in case any notifications are sent to you over messages or a physical courier, neither gets lost. And if you need to reach out to the insurer or the Third Party Administrator (TPA), to raise a claim, clear a doubt regarding your policy, or make certain alterations in the policy, you can do so conveniently.

2. Permanent Exclusions & Waiting Period

It’s true that when choosing the best health insurance plan that caters to your customised medical and financial requirements, you have to factor in the permanent exclusions and waiting period for

-still, when you get your hands on your health insurance policy document, it is essential to cross-verify the exclusions and waiting period. If you find any discrepancies from what had been previously discussed with you, you can always reach out to the insurer and discuss the same.

3. Policy Number

The health insurance policy number is a unique set of alphanumeric combinations that is instrumental -

  • For health insurance providers to determine the details of your coverage and the various features that have been availed by you.
  • For policyholders when it’s time for raising claims and settlement of the same.
  • For the insured who needs to provide this number (or the health insurance card with the number in it) during hospitalisation if one wants to avail of the cashless mode of a health insurance claim.

Since the policy number is a difficult one to memorise (unless of course, you have a photographic memory) and yet a necessity to have on you because medical emergencies don’t exactly knock on your door before arriving. The best way out would be to carry your insurance card in your wallet that comprises your policy number.

(P.S. In case it is a group health insurance plan’s policy document that you are looking for, make sure that each of the policyholders has a unique health insurance number assigned to them.)

4. Any Co-insurance/Deductible/Copayment Clause

Co-insurance, deductible, and copayment are all various health insurance jargon that is instrumental in deciding if and how much the policyholder is held financially liable towards paying the claim. This payable might be mentioned as a fixed amount (deductible and copayment) or as a % (copayment and coinsurance).

  • In general, health insurance experts request that you lay off from the copayment feature considering its short-term perk and long-term financial burden. However, in case the policyholder is a senior citizen or affected by severe pre-existing medical conditions who are facing issues in availing of health insurance plans (or getting ones that are too expensive), copayment might be the only option.
  • Deductibles and co-insurances (the latter is only applicable if chosen by a policyholder in the case of a deductible), are beneficial in the cases of a base health cover or the case of Super Top Ups if the policyholder wants a deduction on the premium that their plan requires of them.

While whether the overall financial; implications of these are on the positive or the negative side is subjective, it must be your decision if you want them in your policy or not.

So, when you get your hand on the health insurance policy document, look out for any hidden such clauses that you haven’t (or have) agreed to and contest the same if it's against your preference. Else, you will find yourself trapped in a huge financial disaster during claim settlement that would require you to put your hands in the proverbial cookie jar of savings, despite having substantial health insurance coverage.

5. Premium Calculation Breakup

Ravi had his first health scare during the pandemic. He had never been more motivated to avail of a health insurance policy. Multiple YouTube videos and free tools for the comparison of health insurance plans later, he approaches an unbiased health insurance expert and mentions his pre-existing medical complications, expectations from the coverage (that can be met by health insurance add-ons), exact residential address, and age. The expert offers him an option of 3 plans from the best health insurers across the nation and mentions the approximate premium for each of them. Considering his optimum financial awareness he shows interest in the premium calculation breakdown and the expert tells him that the same will be offered in his policy document.

Well, the expert was right. Any health insurance policy document comprises a tabulated breakdown of the premium that a policyholder is expected to pay. The factors can include the

  • Base premium amount
  • Loading charges (if any)
  • Tax deduction under Section 80D
  • Cost for any additional add-ons availed

-among others.

Such a detailed presentation establishes transparency between the health insurer and the proposer and policyholders and strengthens the credibility of the health insurance provider. So, make sure to check this premium calculation and match it up with the estimated value provided by the expert or the free tool that you used.

6. Pre-existing conditions (if any)

Health insurance plans are tuned to customisation for a specific reason - each policyholder presents a unique situation with a diverse combination of pre-existing medical conditions. Keeping this in mind health insurers across the industry have crafted tailored plans that target specific health conditions -

And since some of the ailments (like the ones mentioned above) are generally excluded from health insurance plans, potential policyholders are requested to disclose such medical conditions so that the insurer and its underwriting team can reconsider the case and either reject the application of the plan or offer the policy with added loading charges.

Your health insurance policy document will comprise the details of any such medical conditions that have been disclosed and considered by the insurer so that during claim settlement, no hurdles are raised and the coverage can be conveniently accessed to treat such conditions.

7. Coverage details including Health Insurance Add-Ons

When we talk about health insurance customisation, we talk about health insurance add-ons that might range from -

  • Coverage for deliveries and newborns
  • Consumable cost coverage
  • Unlimited Restoration
  • Copayment waiver add-on
  • Hospital Cash
  • Inflation-shield
  • Coverage booster
  • No Claim Bonus protection
  • International coverage and Enhanced global coverage

Such health insurance add-ons cater to one’s medical and financial personal goals and fetch nominal costs that are added to the base premium. While a majority of these add-ons are incredibly beneficial, not all are meant for a policyholder.

When you decide upon a plan, your expert must have given you a suggestion about which add-on would best suit your medical interest. Look into your health insurance policy document to make sure that the add-ons included in your policy are the ones that you asked for. Any redundant add-on will put unnecessary financial pressure on you, the policyholder.

8. Free Look Period

Each health insurance provider offers you a span of 15 to 30 days of free look period during which you are allowed to scour through the health insurance policy that you have availed and make a final choice if the policy is best for you.

A serious consideration during this period would help you prevent any hassles involved in health insurance portability and a whole lot of financial regret over hiked premiums, low no-claim bonus, one-time restoration only, multiple exclusions, or extensive waiting periods.

Your health insurance policy document will disclose this freelook period span. Mark it and cross it on your calendar. And during this time, leave no stone unturned in judging your policy since you will be the one banking on the plan for the rest of the tenure in all its financial and medical glory.

9. Frequency of premium payment

In an attempt to facilitate the financial affordability of health insurance plans and boost health insurance penetration across the nation, as per regulations from IRDAI, insurers have been offering multiple options in premium payment frequency - annual, half-yearly, quarterly, EMI, etc.

During your final interaction with the insurer or the agent from whom you availed of the health insurance plan, you must have disclosed your opinion about what kind of premium payment frequency would best suit you while balancing the rest of your financial liabilities. This frequency would be written in one of the pointers across your health insurance plan.

When going through the health policy document, cross-check and ensure that the frequency included in the doc is the one that you prefer. This confirmation will ensure that you end up paying in an interval that doesn’t add to the burden of your existing financial responsibilities.

10. Claim Process

The claim process for health insurance plans is almost the same for each insurance provider. However, insurers are bound to disclose the details of the claim settlement process in the health insurance policy documents.

(In regards to this, make sure to take note of the contact details of the insurance provider and the documents that you will need to submit during the claim settlement procedure.)

BONUS: Network Hospital Details

When going through the health insurance policy document, you will come across the list of network hospitals (healthcare facilities that have a tie-up with your health insurance provider).

Take note of these facilities since they are particularly effective when you have the opportunity to avail of a cashless mode of claim settlement (for scheduled procedures, since during medical emergencies you don’t have the bandwidth to choose and get admitted).

What are the Steps in the Health Insurance Policy Document Error Correction?

All over the last subheading under which we mentioned the “things to check in your health insurance policy document,” we have been talking about approaching the insurer in case of any discrepancies in the doc. However, to rectify an error in the health insurance policy doc, a policyholder needs to follow a certain protocol that involves the following steps -

STEP 1: Reach out to the insurance provider and notify them about the error over their toll-free number/mail/branch office.

STEP 2: Let them know about the errors in the policy document and the kind of corrections that you require.

STEP 3: Provide the required documents that would be needed to make the rectifications post-cross-verification of the specific details.

STEP 4: Sit back and wait for the new health insurance policy documents to be sent to you.

(As of recent times, some health insurers equip their websites with opportunities for policyholders to apply for changes in the health insurance policy document online.)

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Conclusion

A health insurance policy doc is one of the most crucial documents for a policyholder. It determines the financial and medical implications of the policy that one avails of. And this is also the last stop in ensuring that the policy availed by an individual is best suited for him/her and comprises the features that one has been seeking for their policy all along.

So, holding on to the health insurance policy document checklist is crucial considering that it becomes impossible for a policyholder to go through all the strenuous financial, medical, and medical jargon mentioned in the doc.