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Factors To Consider Before Deciding On A Health Insurance Plan – Forbes Advisor INDIA


The rising incidence of illnesses coupled with the increasing medical inflation has made health insurance plans a must. In India, there are more than two dozen companies offering a plethora of health insurance plans. Each plan has its set of unique selling propositions that sets it apart from the rest. In such a scenario, if you are in the market for a health plan, the choices might overwhelm you.

First, let’s understand how to zero in on the right insurance company. Then, the next step would be to explore and find the right policy.

Step 1: Finding the Right Insurance Company

Here are some factors that you can use in deciding on the right health insurance company –

1. The range of plans offered

Check out the different types of plans that a company offers as well as the plan USPs. Some companies offer a range of products to suit the varied coverage requirements that you have. Choose a company with a diverse range of plans so that you can find the right policy suiting your needs.

2. The network of hospitals

The network of hospitals is extremely important for availing cashless claims. The wider the network that an insurer has, the better it would be. This would allow you to locate the nearest cashless hospital with ease.

3. Claim settlement ratio

The claim settlement ratio points to one thing – what percentage of claims did the company settle in a financial year. A higher ratio indicates that the company is steadfast in settling its claims. A factor that works in favour of the insurer.

4. Claim-based loading

Some companies tend to increase the renewal premium if you made claims in the previous years. This converts to higher premium expenses. As such, avoid companies that follow this practice.

5. Premium rate

Pricing policy is how much premium the company charges vis-à-vis its competitors. You can check the pricing policy by comparing similar plans across different companies.

For instance, the Aarogya Sanjeevani policy offers uniform coverage features across all insurers. Its premiums, however, depend on the insurer’s pricing policy. Compare the premium of the plan across insurers to find the insurer that charges the least. Chances are, its pricing policy would be fair across all its plans.

6. Ease of claim settlement

Insurers have revolutionised their claim process and made it simpler. The following concepts are gaining traction: 

  • AI-enabled claim processing
  • WhatsApp intimation
  • Digital documentation
  • Quicker approvals
  • App-based claim intimation and tracking, etc.

Such facilities speed up the claim process and make it hassle-free. Thus, look for insurers that provide such facilities for quicker claim settlements.

7. Reviews 

Lastly, don’t ignore customer testimonials and reviews. Most insurers showcase their customers’ reviews on their websites. You can check them out. Alternatively, you can talk to your friends and relatives about their insurers. If they have made a claim, find out their claim experience to know which company follows the best practices.

Step 2: Finding the right plan

Once you have zeroed in on the right insurance company, the next, and also the most important, step would be to select the plan. With multiple insurers offering multiple plans, you have a lot of choices. However, choosing the right policy is important.

As such, here are some factors that would help you with the same –

1. Coverage benefits

The first thing that you need to check is the coverage benefits that are offered by different plans. While most plans offer the basic coverage benefits, look for plans that have unique features.

First, assess your coverage needs and then look for plans that offer those. For instance, if you are planning to have a child in the near future, look for plans that offer maternity coverage. Alternatively, if your family is complete, skip such plans.

Second, look for other additional features that might enhance the scope of coverage. For instance, sum insured restoration, high no claim bonus, value-added benefits, annual health check-ups, etc. are some of the features to look for.

Choose a plan which has the most comprehensive scope of coverage. This would minimise your out-of-pocket expenses during claims and give you better financial security.

2. Customization option

Look for plans that allow you to customize the coverage features as per your requirements. This is possible through add-ons that health insurance plans offer. The add-ons help you to opt for additional coverage features as per your needs and make customisation possible.

3. Premium amount

Of course, the premium amount is important. Check the premium charged vis-à-vis the coverage offered. To get a better idea, compare. Compare the premium across other plans of different insurers that have similar coverage benefits. See if the premium is competitive or inflated given the coverage.

Choose a plan with the most competitive premium rate for the same coverage benefits, even if it means selecting another insurance company.

4. Sub-limits

Health plans might have sub-limits on different expenses like room rent, ICU room rent, AYUSH coverage, domiciliary treatments, etc. These sub-limits limit the scope of coverage and might result in out-of-pocket expenses.

As such, choose a policy that has no sub-limits so that you can enjoy the maximum possible coverage.

5. Co-payment clauses

Health insurance plans might have co-payment clauses for different reasons. Co-payments mean that in every instance of a claim, you are supposed to pay the specified part of the claim from your pockets. For instance, a co-payment of 10% means that 10% of every claim would be borne by you.

Common co-payment clauses are applicable in the following instances: 

  • If the insured is aged 61 years and above at the time of buying the policy
  • If you buy the policy in a city belonging to a lower Tier and avail of treatments in a city in a higher tier
  • In the case of specified illnesses and/or treatments

Look for health insurance plans that do not have the co-payment clause. Even if the clause is unavoidable, like in the case of senior citizen plans, opt for plans with a lower co-payment rate.

6. Waiting periods

The waiting period is when specific coverage is not allowed by the health insurance policy. Once the waiting period is over, coverage is allowed.

Health insurance plans impose waiting periods in various instances. These include the following: 

  • First 30 or 60-day waiting period for the coverage of illnesses. This is also called the cooling-off period during which illnesses are not covered. Accidental injuries, however, are covered from day 1
  • Waiting period for specific illnesses or treatments like hernia, fissures, hydrocele, tonsillectomy, cataract, joint replacement, etc. This waiting period is generally 24 months. In some plans, however, the tenure might vary
  • Pre-existing waiting period ranges from 12 months to 48 months. This waiting period is for illnesses or medical conditions that you might have when buying a fresh policy. Complications arising out of existing conditions are not covered during this period.
  • The maternity waiting period might range from 9 months to 48 months
  • Waiting period for the coverage of OPD expenses, bariatric treatments, etc.

Waiting periods are inevitable. However, you can find a plan where the period is low. This is especially relevant if you are looking for maternity coverage or if you have pre-existing conditions and you want coverage for them at the earliest.

7. Discounts available 

Health insurance plans allow various types of discounts to lure customers. Some of the commonly available discounts include the following: 

  • Discount for buying a two or three-year policy
  • Discount for covering two or more members under the policy on an individual basis
  • Discount for buying the policy online
  • Discount for paying the premium in a lump sum rather than in instalments
  • Discount for the existing customers of the company
  • Discount for maintaining a healthy lifestyle
  • Renewal discount if you have not made a claim in the last policy year
  • Discount for choosing a voluntary deductible
  • Discount for availing of treatments at a network hospital 

Look for the available discounts. Choose a plan that offers the highest discount so that you can get the best deal on the premium. 

Now that you have found the best company and the most suitable plan, you might think that your work is done. It is not. You should keep in mind another aspect – choosing the right sum insured.

Step 3: How To Find the Right Coverage Amount?

An optimal sum insured is important to ensure that your health plan sufficiently covers your medical expenses. A low sum insured defeats the whole purpose of investing in health insurance and is a strict no-no.

Selecting the right sum insured is easier than you think. You just have to consider the following factors: 

  1. The number of members being insured under the policy
  2. Whether you or any other member suffers from any pre-existing condition
  3. The basic cost of hospitalisation and medical treatments
  4. The rising medical inflation 

Most insurers help you calculate the ideal sum insured based on your income, expenses, existing coverage and members to be insured. You can also estimate the optimal requirement through a simple formula which is as follows: 

Sum insured = 50% of your annual income + total hospitalisation costs incurred during the last 3 years

For instance, say your annual income is INR 15 lakh and in the last three years you have incurred a hospital bill of INR 5 lakh. In this case, the optimal sum insured would be calculated as follows: 

50% of INR 15 lakh + INR 5 lakh = INR 12.5 lakh

Step 4: How To Afford a Health Plan

The premiums of health insurance plans are affordable. Moreover, insurers offer you the facility of installment premiums wherein you can pay the premium monthly, quarterly or half-yearly. This makes the health plans affordable.

Furthermore, if affording a high sum insured poses a challenge, you can opt for super top-up health plans. Super top-up plans help in enhancing the coverage while keeping the premium low.

For instance, say you want coverage of INR 15 lakh but the premiums are unaffordable. In such cases, you can opt for a comprehensive health plan of INR 5 lakh or INR 10 lakh and add a super top-up plan of INR 10 lakh or INR 5 lakh respectively.

The super top-up plan would help you enjoy an aggregate coverage of INR 15 lakh. However, the aggregate premium would be lower compared to buying a health plan of INR 15 lakh.

Bottom Line

Just buying health insurance is not enough. You need to ensure that you have picked the right insurer and the right plan. So, keep the aforementioned points in mind and do your research to select the right health insurance plan.