Chapter 32: Medical Insurance
|God heals and the Doctor takes the fees.
- Benjamin Franklin
In certain cases, medical care can be expensive and costs are zooming upwards day by day. You acquire medical insurance for the same reason as other kinds of insurance - to protect yourself financially. By going in for medical insurance, you can protect yourself and your family if struck by disease. While no one wants to fall ill, the last thing one wants to worry about when is whether one will be able to afford good medical care. On the other hand, if you have been prudent enough to obtain insurance, many of your costs can be covered by a third-party payer, namely, the insurance company, thus relieving you of considerable anxiety and concern.
The traditional form of health insurance is called indemnity insurance (also known as fee-for-service ) , in which the insurer pays for the cost of covered health care services after they have been provided. In most indemnity insurance plans the patient is free to choose his own doctor or hospital.
In India, the insurance business is still a monopoly, so that, for all practical purposes, the only medical insurance policy available for most of us is MediClaim, through the subsidiaries of the General Insurance Corporation (GIC). The government does have special schemes for its employees: the ESIS (Employee State Insurance Scheme) and the CGHS (Central Government Health Scheme). Many employers now provide medical insurance as a standard perquisite to many of their employees - this is called group insurance - and the premium is less than a stand-alone personal insurance policy. In many cases, the employer pays part of the cost or all of it. Not all employers, however, offer health insurance. Your employer may not subscribe to a health insurance scheme, especially if you work for a small business or work part-time. In such a situation, you might still be able to obtain group insurance (and thus save money) through a labor union, a professional association, club, or any other organization you belong to.
However, if this is not possible, then you will need to obtain coverage for yourself (and your family) on your own by taking out a personal policy.
Given the fact that the insurance business in India is still a monopoly, the only decisions you will need to make are very simple: whom to insure (some or all the members of the family); and how much to insure for. This situation is in sharp contrast to that in the USA, where there are a wide variety of medical insurance schemes on offer --- and choosing between HMOs (health maintenance organizations) and PPOs (preferred provider organizations) can leave most patients very confused! While taking out a policy is a simple matter ( after all, the insurance company is happy to earn the premium you pay!) getting reimbursement for the expenses you incur can be a tedious process; the company does not want to part with their money! This is why it is important that you go in for an agent to take out your policy, so that he can help to get your claim sanctioned in case you fall ill.
In the future, with increasing liberalization, as the insurance business in India is opened up to the private sector, many more options will become available for patients to choose from. However, not all the changes will be for the best --- and you will need to use your judgement when making a decision as to which policy to select for your family. Premiums are likely to increase sharply each year. Since the cost of medical treatment is rising faster than the rate of inflation. Also, as you get older, the likelihood of your making a claim increases, and premiums will jump, often dramatically.
Read the fine print on your policy, and make sure you understand precisely what your policy does and does not cover, so that unpleasant surprises do not crop up later on ! Heres a checklist of some aspects to be clarified before taking out a policy. Is the cover for treatment and operations restricted? Policies will often exclude factors such as : treatment for alcohol and drug abuse; dental treatment; HIV/AIDS-related illnesses; infertility treatment; normal pregnancy; cosmetic surgery (to solely enhance appearance). This list is not exhaustive and you should ask the insurer for details about your particular policy.
The medical insurance document requires that you declare everything on the application form, even if you think it trivial and unimportant. This document needs to be accurate as it forms the basis of the contract you make. If certain information is inaccurate or has been left out, the insurer may refuse to pay your claim.
Remember that insurance policies generally only cover you for disorders which have not affected you. Conditions that you are suffering from or have suffered from in the past are known as pre-existing conditions, and most individual policies (and some group policies) will not cover pre-existing conditions. Some policies cover a pre-existing condition only after a specific period of time has lapsed since your last treatment or visit to a doctor for the same condition. You might have a waiting period of between six months and two years before coverage begins. check your policy carefully to check if you can be denied coverage for a pre-existing condition.
When you want to make a claim, it is best to contact the insurer before you actually receive treatment, if possible. The insurer can confirm the specifics of your cover, check that the treatment is within any relevant limits, and let you know whether you should pay first and then be reimbursed or whether the insurance company can make arrangements to pay the hospital direct.
It is very important to ensure that your paperwork is complete and accurate when you submit a claim for reimbursement to the insurance company. Dont make false claims under any circumstances: not only are you likely to be caught, but you will also create problems for yourself in the future when you do make a genuine claim ! Make sure that you have filled in all the insurance companys forms correctly; and that your doctor has entered all the required information. You will also need to submit your medical records, as well as the bills and receipts. Consequently, make sure you keep all these items carefully, and retain a photocopy of everything you submit!
One particularly nagging question is:
What action can you take if the insurance company rejects a claim that you feel is valid? If the company refuses your claim, insist on a reply in writing, so that you can appeal against such rejection, say, to the consumer forum. You need to know how to stand up for your rights! Resubmit your claim in writing and express your views as to why you feel it should not have been rejected. Ensure that your problem is stated in a clear, concise manner. Also, do forget to include all appropriate documentation with the letter, including the following details: your policy number, relevant test results, medical records and doctors statements that back up your claim. Most importantly, clearly state what action you want your insurance company to take to solve the problem. Keep copies of all your correspondence ! Dont be afraid to ask your physician and your insurance agent to contact the insurance company on your behalf. If your problem is not solved by your initial letter, you should appeal to a higher level within the insurance company. Remember that you are dealing with a bureaucracy and you will need to be persistent! You can fight for your rights, either by tackling the company itself, or through legal action, if need be.