5 big gaps in Health Insurance: The hospital incurs losses at the time of claim, know the hidden conditions of the policy and how to fix them.

As soon as the attendants show the health insurance card worth Rs 10 or 20 lakh on the TPA desk after being admitted to the hospital, they think that the insurance company will pay every single penny of the treatment. But on the day of discharge, when out of the bill of Rs 4 lakh, the insurance company passes only Rs 2.5 lakh and the remaining Rs 1.5 lakh is asked to be paid in cash, the family is shocked. This situation arises not because of any deception or fraud, but because of ‘policy gaps’ and hidden clauses ignored while purchasing the policy. If these 5 most common gaps are not understood in advance, then even after paying huge premiums, it is sure to put a huge burden on the pocket in an emergency.

The most dangerous and common gap in health insurance is ‘room rent capping’. In many traditional policies only 1% of the total sum insured is allowed as room rent per day (i.e. ₹5,000 per day on a ₹5 lakh policy).

• Reason for getting stuck: If you choose a private room in the hospital for ₹ 8,000 per day, the insurance company will not only deduct ₹ 3,000 extra for the room, but will also apply the ‘Proportionate Deduction’ rule. Under this, all related expenses like doctor’s visiting fees, nursing charges, OT charges and surgeon fees will also be reduced in the same proportion (about 37.5%), which results in a dent of lakhs in the bill.

• How to fix it: While purchasing or renewing the policy, choose a policy with ‘No Room Rent Capping’ or ‘Single Private Room’ eligibility. If the existing policy has capping, avail the ‘Room Rent Waiver’ rider by paying a nominal additional premium.

Since the Covid-19 pandemic, the share of non-medical/consumables items in the total medical bills of hospitals has increased from 10% to 20-25%.

• Reason for getting stuck: As per IRDAI guidelines, a normal base policy does not cover more than 68 medical items such as syringes, gloves, PPE kits, cotton, pulse oximeter probe, diapers, adhesive tape and thermometers. When a patient has a major surgery or a 4-5 day stay in the ICU, the bill for consumables alone reaches ₹40,000 to ₹80,000, which the base policy defies.

• How to fix it: It is mandatory to add a ‘Consumables Cover’ or ‘Claim Protector’ rider to your policy. This rider is very cheap (between ₹500 to ₹1,000 per year), but it pays your entire non-medical bills at the time of claim.

Seeing advertisements of cheap policies with low premium, people often buy the policy without reading the rules, where the secret of ‘co-payment’ is often hidden.

• Reason for getting stuck: Co-payment means that the patient has to pay a certain percentage (10%, 20% or 30%) of each treatment bill from his own pocket. If the policy has a 20% co-pay clause and the final hospital bill turns out to be ₹5 lakh, the insurance company will only pay ₹4 lakh and ₹1 lakh will essentially have to be paid by you from your savings. This clause is specifically imposed on senior citizen plans or for treatment in a particular city/zone.

• How to fix it: Always choose a policy with ‘Zero Co-pay’. Even if co-pay is mandatory due to old age of the parents, ensure that this limit does not exceed 10%, or balance it through corporate top-up.

Often, as soon as people take the policy, they assume that cashless treatment for every disease will be free from the next day, whereas the reality is exactly the opposite.

• Reason for getting stuck: Every health insurance has an initial waiting period of 30 days (except in accidental cases). Apart from this, there is a specific waiting period of 1 to 2 years for common diseases like Cataract, Hernia, Kidney Stone, Piles and knee replacement. Whereas for chronic diseases (PED) like BP, sugar, thyroid or asthma, earlier this period used to be 3 to 4 years, which has been reduced to a maximum of 3 years in the new rules. If treatment is done during the waiting period, the entire claim gets rejected.

• How to fix it: Do not hide any medical history while buying the policy. Opt for ‘Waiting Period Reduction’ rider to reduce the waiting period from 3 years to 1 year or directly get covered from Day-1, so that no claim gets rejected in future.

About 65% of the total health expenditure of Indian families is spent not on hospitalization but on doctor’s consultation fees, blood tests, MRI-CT scans and routine medicines (OPD Expenses).

• Reason for getting stuck: Most health insurances pay claims only if the patient is hospitalized for at least 24 hours (except day-care surgeries). Bills for routine doctor visits or expensive tests are not covered in the base policy. Apart from this, insurance companies impose ‘sub-limit’ (capping) on ​​modern technologies like robotic surgery, stem cell therapy or immunotherapy, due to which the full cost of modern treatment is not covered.

• How to fix it: If your family requires regular doctor checkups or tests, take a policy with ‘in-built OPD cover’. Also, ensure that the policy document provides cover up to 100% sum insured without any sub-limit on ‘Modern Treatments’ and ‘Robotic Procedures’.

Instead of keeping your existing health insurance policy locked in a drawer, take out its ‘Policy Schedule’ document today and check the terms and conditions of room rent limit, co-payment and consumables. If your policy has these deficiencies, add these riders 45 days before your next renewal date or get your policy ‘ported’ (Health Insurance Portability) to a modern, feature-rich plan. The biggest advantage of portability is that your old No-Claim Bonus (NCB) and the elapsed waiting period remain completely safe and you get all the premium features in the new policy without any additional risk.