When Rajesh Sethia’s (name changed) mother-in-law went to a hospital in Thane last year, the Rs 2-lakh health insurance policy in her name delivered a shock. It barred use of air-conditioned rooms and cashless facilities were denied as the lady suffered from hypertension.
Mediclaim-type health insurance policies, that reimburse expenses, are getting trickier and meaner and sometimes even frivolous. General insurance companies are introducing caps in the policy — at last count, there were 12. For example, most health insurance policies have a 1-2 per cent cap on hospital room tariff.
National Insurance allows one per cent of the policy amount to be used for daily room rent. So for a Rs 1 lakh policy, room rent has to be Rs 1,000 only.
In Mumbai, that can be quite difficult. But United India doesn’t have any cap at all and Oriental Insurance has a one per cent cap. Reliance Capital has a two per cent cap, Royal Sundaram has a 1.5 per cent or a flat Rs 1,500 per day cap.
Mumbai-based certified financial planner Mukesh Dedhia says: "Sometimes I feel so confused, I do not know what to recommend. Consumers have to do some self study." Consumer court lawyer Uday Wavikar says: "If you read the fine print you will never buy health insurance. Claims are also being refused for frivolous reasons."
Wavikar says a 32-year old client suffering a paralytic stroke had admitted he was an occasional drinker and the doctor noted it down. The insurance company used that to show the client as an alcoholic for 20 years. "Imagine a boy from a Jain family alcoholic since he was 12. No other medical proof was cited," Wavikar said.
Delhi-based insurance broker, Rahul Aggarwal says: "The companies feel a person must take a room in a hospital matching his financial status and if they want a better room they should go for a better policy."
KN Bhandari, the secretary general of the General Insurance Council, said the industry is discussing a problem. He said: "At least there is choice in the market and the consumer can study the policies and choose what he likes. We may also introduce a standard health policy that all insurers will offer. It is the job of the insurance agent to tell the consumer what are the specific features."
Aggarwal says, "Tariff has fallen for insurance products like motor and household has led the companies to tighten the screws on mediclaim policies. Earlier, sometimes companies would ignore such details if the total claim was within the limits, but not any more."
Health policies offered by life insurance companies, which do not reimburse, but offer lump-sum payments, may just become more popular now. Says Sujata Dutta of Tata AIG Life, "Our policies offer a specific sum for each day of hospitalisation and particular illnesses and surgeries. It is all decided at the time the policy is bought."