Family health insurance plan is a complete package which is specially designed to offer protection to the insured and his family. Under a family health insurance plan, you can cover yourself, your spouse, dependent children (above 90 days) and dependent parents (65 years) against health issues.
Family health insurance plans also take care of the treatment in case of a critical illness or serious medical conditions. Taking a family health insurance plan works out cheaper than purchasing individual health insurance plans for everyone. Insurers in India provide customized health insurance to families, based on their specific needs. You have the option to choose from various plans available, based on the needs of the family and the medical history of the family.
Once you take a family health insurance plan, your worries regarding the health care emergencies will be at bay. Whether it is the risk of a heart attack or any other medical worry, you can always shelter your family from the financial constraints by using a family health insurance plan.
Features & Benefits of Family Health Insurance
Health insurance plans for families have a number of benefits that they offer.
It is easy on your pocket: Health insurance plan for family can help you save money. You can cover your entire family in a single family floater insurance plan. When compared to the cost of the individual health insurance plans for each member, health insurance plan for the family will work out to be cheaper.
Ease of process: Nobody wants their loved ones to suffer from a medical emergency. But unfortunately, health emergencies can strike when we expect them the least. However, with a health insurance plan for the family, you are at least able to protect your family from any financial constraint due to medical emergencies. A single policy provides the required protection to your entire family. You don’t need to go through the hassle of maintaining individual policies and pay premium for all of them. Instead, a health insurance plan for the family will be a hassle free option.
Discounted rates: When you choose a family health insurance or a family floater plan, you can avail great discounts that policies usually offer. To secure the future of your family against any medical emergencies, a health insurance plan for the family is what you need the most. Couple it with the discounts and the savings that you make – family health insurance plans are the way to go.
Cashless hospitalization: Most health insurance plans for families provide the option of cashless hospitalization. Health insurance companies have tie-up arrangements with several hospitals all over the country. Through these tie ups, the hospitals become part of the network. If a health insurance policy offers cashless facility, a policyholder can take treatment in any of the network hospitals without having to pay the hospital bills. The payments to hospital are made by a third part administrator who acts on behalf of the insurance company.
Health Insurance Plan for Family – Eligibility Criteria
The specific eligibility criteria under a few health insurance plans for families may vary. But the general conditions of eligibility are the same. These are set out below:
Entry age for the Policyholder/Proposer under Family Health Insurance Plan: In case of a family health insurance plan, the eldest person is the policyholder. The entry age for policyholder/proposer is from 18 to 65 years. However, some insurers may allow entry age of 70 years and above.
Entry age for Family Members under Family Health Insurance Plan: In case of adults, the minimum entry age for adults is 18 years. The maximum age is 65 years or 70 years, as the case may be. In case of dependent children: the minimum age is from 90 days (some insurers may allow it from 30 days as well) to 25 years.
What is Covered and Not covered under a Family Health Insurance Plan?
Health insurance plans for families provide a great deal of coverage. The common coverage under most family floater plans is as below:
In-patient Hospitalization: Medical expenses incurred due to hospitalization of any person covered under the family health insurance plan are covered. The hospitalization should be for more than 24 hours.
Pre-hospitalization Expenses: Before hospitalization, expenses may be incurred as a number of tests have to be conducted. These expenses are termed as pre-hospitalization expenses. A family health insurance plan will cover the cost of these expenses.
Post-hospitalization Expenses: Any medical expenses which may be incurred once the patient is discharged from hospital are termed as post-hospitalization expenses. Therefore, if any diagnostic tests have to be conducted after discharge, the family health insurance plan will provide coverage for such expenses.
Hospital Cash: A number of family health insurance plans provide a daily allowance in case of hospitalization of the patient. This can be utilized to cover the cost of the transportation or other basic requirements of the person who is attending the patient hospitalized.
Day care treatment: In a few instances, hospitalization may not be required. The medical condition may be treated through a day care stay in the hospital. For example, a cataract surgery takes only a few hours. Policies also cover for such day care treatments.
Similar to coverage, the exclusions under a family health insurance plan can vary based on the insurer. It is important to read through the policy document carefully to understand the exclusions. The list of common exclusions is as below:
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- -Any claim raised within the 30 days waiting period of the health insurance policy.
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-Any sexually transmitted diseases.
-Any treatment and expenses incurred due to routine medical check-ups.
-Any treatment/surgery done for gender reassignments or for gender change.
-Artificial life maintenance, including life support machine use, where recovery or restoration of the previous state of health is not possible.
-Any treatment undergone due to surgery or a plastic surgery, aesthetic treatment, or any further consequences due to such treatments.
-OPD Treatment.
-Any illness or injury directly or indirectly causing or arising because of breach of any law by the insured who has a criminal intent, war, nuclear, chemical or biological attack or weapons, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.
-Illness or Injury caused due to consumption or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.
-Any act of self-inflicted injury, suicide or attempted suicide.
Mediclaim Policy for Family
A mediclaim policy provides the policyholder with financial assistance in case of a medical emergency. Such a policy provides assistance through cashless facilities or reimbursement during medical treatments and hospitalisation.
In case of a mediclaim policy, the insurer providers reimburse the policyholder for any medical expenses that he/she might have incurred during the policy period. In order to be reimbursed, the insured should submit the relevant bills of the hospital.
Mediclaim policy also provide the option of cashless hospitalization. Health insurance companies have tie-up arrangements with several hospitals all over the country. These hospitals are part of the network. If the insured wishes to avail the cashless hospitalization option, he or she can take treatment in any of the network hospitals without having to pay the hospital bills. The payments to hospital is made by a third party administrator who acts on behalf of the insurance company.
Many insurers also provide overseas mediclaim policies. Under such a policy, the insurer can seek treatment in both India and overseas. The chief difference between a mediclaim and a health insurance plan is the amount of sum insured. In case of a health insurance plan, the premium paid much higher and the sum insured is also high. Under a mediclaim policy, the sum insured is much lower.
Types of Family Health Insurance Plans
A family health insurance plan provides a broad range of protection to those who are covered under the policy. Based on the kind of coverage provided, these health insurance plans can be broadly divided into two categories:
Medical insurance: This policy is aimed at reimbursing the costs incurred in case of hospitalization of those who are insured. The insurer can either provide a cashless facility or a reimburse the insured for the expenses incurred.
Critical Illness: The other type of family health insurance plan is a policy cover against chronic diseases. These could be in the nature of heart attack or kidney stones etc. Subject to the terms and conditions of the policy, typically such a policy will provide a lump-sum amount incurred for the treatment of such condition. It is important to note that a critical illness policy cannot be purchased as a single policy for the entire family.
Family Health Insurance Claim Process
It is important to understand the process for registering a claim under a family health insurance plan. As discussed above, the insurer can either provide a cashless support or reimbursements. The process for both is set out below. However, there could be variances based on the nature of the policy, insurer and the hospital where the treatment has been taken.
If claiming under the cashless process:
-Visit the insurance desk of network hospital.
-Provide ID card for identification.
-Fill up a pre-authorization form provided by the hospital.
-The hospital usually has a third party administrator (TPA) who acts on behalf of the insurer. The TPA checks the documents and approves the cashless claim as per the terms and conditions of the coverage.
-Usually, a field executive is appointed by the insurer who makes the claim process easy for the policy holders.
If claiming as a reimbursement:
-In this process, the insurance coverage is only provided once the insured is discharged. Therefore, it is important to collect all the bills and other original documents from the hospital at the time of discharge.
-The reimbursement claim form needs to be submitted to the claims team of the insurer or the third party administrator. All the bills, medical and consultation reports and any other document as required in original need to be attached.
-The claim will be validated by the insurer or the third party administrator.
-The insured will receive the sum insured as per the policy terms and conditions.
FAQs
Are there any tax benefits which can be availed through health insurance plans?
The premium paid towards the insurance policy can be claimed as a tax-saving deduction under Section 80D. A taxpayer is permitted deduct up to INR 25,000 annually for a health insurance policy, where the premium is paid for yourself. In case the premium is paid for parent, a deduction of INR 30,000 can be claimed
What is claim settlement ratio?
Claim settlement ratio indicates the ratio if claims settled against claims reported during the year. Always make sure to check the ratios of your health insurer before you purchase the plan.
The major reasons for refusal of claims for health insurance are:
-Related to PED
-Related to waiting Period
-Hospitalization not justified
-Diagnostic/Investigation purpose
-Other Exclusion Clauses of the policy
-Misrepresentation/Fraud
-Experimental/Unproven Treatment
Is there a waiting period for claims under a health insurance policy?
Usually, there will be a 30 days waiting period starting from the policy inception date. During this period any hospitalization charges will not be payable by the insurance companies. However, emergency hospitalization occurring due to an accident is excluded. There is no waiting period applicable for subsequent policies under renewal.
What is a pre-existing condition in the context of a health insurance policy?
This denotes any medical condition/disease that exists before you obtain health insurance policy. This is a critical aspect as usually the health insurers in India will not cover such pre-existing conditions within 48 months of prior to the first policy. The cover for pre-existing conditions can be considered for payment after completion of 48 months of continuous insurance cover.
What is the maximum number of claims allowed over a year?
Unless the policy specifies a cap, any number of claims is allowed during the policy period. But remember that the sum insured is the maximum limit under the policy.
What is “health check” facility?
Some health insurance policies pay for specified expenses towards general health check up once in a few years. Usually, this is available once in four years.
What are the factors that affect Health Insurance premium?
Age is a major factor that determines the premium. Previous medical history is another major factor that determines the premium. Claim free years can also be a factor in determining the cost of the premium as it might benefit you with certain percentage of discount.
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