Individual Health Insurance

In simple terms, an individual health insurance policy means a separate policy for each of the family member with individual sum insured. To make things easier, let's consider Gupta family from Mumbai. Mr. Gupta (50) has recently bought Apollo Munich individual health insurance for himself, his wife (30), daughter (20) and son (18) for a coverage of Rs. 3 lakh each.

Although Mr. Gupta paid a whopping amount of approx. Rs. 24,500 towards the premium, there are few things he considered before investing in the plan. As Mr. Gupta has recently undergone gall bladder surgery, he wanted to ensure that his medical condition doesn’t unreasonably lead to waiting period for the rest of the family members. Also, he wanted to block a dedicated sum insured for each family member. These reasons encouraged him to decide on the individual health insurance for the family. While we are at it, let’s delve deeper into some pros and cons for opting the individual health insurance for the family members.

Pros:

• The sum insured remains solely for the insured members. Even though the total claims raised by any member exceeds his own sum insured, he cannot dig into any additional sum insured and hence every insured has a guaranteed coverage amount at their disposal whenever required
• Even parents and in-laws can be a part of this coverage at additional premium
• Suitable for older families as they are prone to greater health risks
• If any insured member has a pre-existing condition as per policy guidelines, the rest of the members need not wait to claim until the waiting period ends
• Discounts on premiums if more than two members
• There is no maximum age for renewal

Cons:

• The individual insurance for the families works out to be costlier than the family floater
• The individual coverage is not suitable for younger families

• Medical Expenses
• In-Patient Hospitalization
• Pre and Post Hospitalization Expenses
• Day Care Procedures
• Cashless Facility
• Lifelong Renewability
• Dependent children covered up to 25 years of age
• Domiciliary Hospitalization
• Road Ambulance/Emergency Ambulance
• Organ Donor Expenses
• Alternative Treatment - AYUSH
• Pre-existing conditions post waiting period

Cost towards premium is one of the major deciding factor while opting for any insurance policy. Below are few deciding factors on the premium calculation:

• Administrative and Promotional Costs: Designing of policy, underwriting costs, marketing and advertising costs, brokers’ commission are some of the costs involved under this canopy and where do you think they are recovered from? Of course, through the premiums paid.

• Savings from Investments: When you pay the premium towards the insurance policy, the insurance company put that money into various public investments. Health insurance premiums are calculated basis returns from these investments.

• Medical Underwriting: This is where the risk evaluated and crucial decisions are taken to prevent the insurance company from making any losses.

• Rate of Mortality: The rate of mortality varies for different age and income bands and is usually high for older customers. For example:

A. Premiums are more if sum assured is higher

B. Premiums are higher as one grows old

C. Premiums are inflated for those suffering from lifestyle illnesses like blood pressure or diabetes

• Personal Medical History: Insurance companies may or may not require you to undergo a medical check-up before the insurance policy is issued. However, your medical history also decides policy premium you would be required to pay. Keep in mind, habitual smoking and drinking summons higher premiums.

• Community Rating: The geographical location, lifestyle habits, overall development of the region along with the trade activities and political stability of the place are few other influential factors that decide the premium amount.

• Band Rating: Under this segment, the insurance company settles on a base rate to be charged for a specific set of people with the similar attributes. These include aspects like group size, geographical location, gender, age, etc. For example: a young and healthy family will pay less premium as compared to a family comprising of senior citizens.

How to make a Claim?

There are two ways to make a health insurance claim - reimbursement or cashless. For both the methods, you need to intimate a claim to the insurer immediately or within 24 hours in case of an accident. You need to download the claim form and submit the same with the following documents:

• Duly filled claim form
• Medical Certificate/ Form which is signed by the treating doctor.
• Discharge summary or card (original), availed from the hospital.
• All bills and receipts (original)
• Prescription and cash memos from pharmacies/ the hospital.
• Investigation report
• If it is an accident case, then the FIR or Medico Legal Certificate (MLC) is required.

• ICICI Lombard - Personal Protect Insurance Policy
• Bajaj Allianz - Individual Health Guard
• Oriental Health Insurance - Individual Mediclaim
• Star Health Insurance - Medi Classic Insurance

• Proof of Age: Acceptable documents are Birth Certificate, PAN Card, Voter’s ID, Driving License, Passport, School or College Certificate, etc.
• Photo Identity Proof: Aadhaar Card, PAN Card, Driving License, Passport, Voter’s ID, etc.
• Proof of Address: Acceptable documents are Ration Card, Telephone Bill, Electricity Bill, Passport, Voter’s ID, Bank A/C Statement, etc.
• Proof of Income: Salary Slip, Employer’s Certificate, Form 16, etc.
• Medical Check-up: If asked by the insurance company
• Passport size photograph