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World Health Day 2019: Your ultimate medical insurance guide

Choosing the right health insurance policy is important to ensure a sound coverage. © Shutterstock

We share expert-backed tips and suggestions on choosing the best health insurance policy. Health insurance is one of the vital tools for ensuring universal health coverage, a significant goal of the World Health Day campaign.

Written by Ajay Pal Singh |Published : April 7, 2019 10:31 AM IST

In a developing country like India, middle class and lower middle class sections account for the majority of the population. On many occasions, they fail to access the high-end healthcare services required for their conditions. This, along with a host of other factors has increased the disease burden of our country manifold. As per the findings of a 2019 report by WHO, around 100 million people worldwide are being pushed to poverty every year as they have to bear the burden of expensive healthcare systems. So, universal health coverage, which is also promoted by the WHO as part of its World Health Day campaign, is of utmost importance at the moment.

Apart from government initiatives to ensure mass access to primary and subsidised healthcare facilities, the other tool that can widen the base of health coverage in India and make expensive treatments affordable to the economically weaker sections is, a good insurance policy. However, choosing the right health insurance policy is important to ensure a sound coverage. But this can be a challenging task, given the fact that the insurance policies come with a lot of complex norms, many hidden costs, limits, sub-limits, so on and so forth. Lack of awareness and incomplete understanding of the insurance policy frameworks may lead to a wrong choice. There are a few factors that one needs to keep in mind while choosing a health insurance policy like limitations of the policies, clauses for exclusion, and premium vs. benefits, says Jitendra Solanki, a SEBI-registered investment expert. Remember, the right insurance policy that matches your financial condition will arm you up with sufficient financial back-up that you need during your or your family's health emergency.

Do not be in a rush while choosing a health insurance policy. Make a list of at least 5 different policies and take time to read each of them minutely. Weight in the limits and benefits properly before picking up a health insurance policy. It's best to consult your close ones who are already using some policy. Identify the limits that are there in the policies. Are there any sub-limits, are there any limits on surgery? advises Solanki. On World Health Day 2019, we share expert-backed tips and suggestions on choosing an insurance policy that suits you the best.

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A health insurance policy can come with two major sub-limits: One on room rent and another on a specific treatment. There is a maximum cap in all he policies which is generally based on the financial aspect of the policy, not the coverage aspect. In case of cap on room rent, you will find 1 per cent of the sum assured is the maximum a company will reimburse, adds Solanki.


You should asses the limitations that are there in a policy, which gives you an estimate of how much claim you can expect from the company. There are multiple limitations included in your regular health insurance policy which can impact the final reimbursement amount. "For example, for a particular surgery a company may offer a maximum of one and a half lakh, even though you are having a five-lakh policy, explains Solanki.

Clauses for exclusion

This factor makes choosing a suitable health insurance policy more complex. They can affect you during an emergency situation. The exclusion can be regarding a pre-existing disease, surgeries, so on and so forth. In most of the health policies, you will find a 2-year waiting period for joint-knee replacement and for pregnancy, this period is somewhere between 4 to 6 years, says Solanki.

Premium vs. benefits

As you already know, a premium is the amount of fee that is paid by the policy holder on a yearly basis to the insurance company for the benefits that it offers. If you are looking to purchase a health insurance policy, it is important to understand the benefits you are getting vis-a-vis the premium you are paying. Companies with sub limits will ask for lower premium whereas companies without any sub-limits, will ask for a higher premium amount, says Solanki. He further affirmed that people in general tend to go for low premium policies without looking at their limitations which later make things difficult for them in emergency situations.

Policies for the senior citizens: What to look for

Ageing can take a toll on your body and having a good health insurance plan for that time is essential. There are numerous health insurance plans available for senior citizens that makes the job to choose the best one a bit more difficult. You should opt for a policy that not only covers hospitalisation costs, but also takes care of the cost of treatment that doesn t require hospitalisation. With various sub-limits in majority of the healthcare plans that are available for the elderly people, it is important that you do a thorough research before gifting your parents a secured future.

Family policies: What to watch out for

In this health insurance plan, you cover more than one individual s medical expenses by paying a single annual premium amount. The terms and conditions of family health plans may vary from company to company. Some companies may allow you to include your parents while others only provide insurance for your spouse and children. To find the best healthcare plan for your family, you need to keep in mind that there are two major types of insurance plans: Medical insurance which basically covers the hospitalisation costs and allows to either avail cashless treatment or get the amount reimbursed later; Critical illness insurance that covers only chronic diseases like heart attack, kidney failure, etc. Since you are planning for a health insurance plan for your family, make sure that you compare different policies and opt for the one which offers more additional features and at the same time has a good claim ratio in the market. A claim ratio is difference between the policy issued and the claim a company settles across the year.

Insurance policies you can look forward to

When you select a company, the first thing that you need to look out for, is what their claim ratio. You ll find majority of the good companies having a claim ratio of more than 90 per cent, but if any company has a claim ratio below 70 per cent, be cautious and dig out the reasons behind such low numbers, suggests Solanki.

However, you should not select a company based solely on the claim ratio as other factors like additional benefits (free health check-ups and less sub-limits) also need to be considered. Max Bupa Health Insurance, Apollo Munich Health Insurance, ICICI Lombard Health Insurance, and Religare Health Insurance are few of the best companies that you can opt for while taking up a health insurance plan, adds Solanki.

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