Who is Eligible For Health Insurance?

Picking well-suited health insurance can be a tough job. The eligibility of the policyholder is a critical condition to be considered while investing in a health insurance policy. Knowing and evaluating all the factors that dictate eligibility, before choosing or even considering a plan is crucial to selection simpler.  

Eligibility Factors For Health Insurance in India

Mainly, there are following listed factors on which eligibility of a health insurance plan depends:

• Age: Most insurance providers in India prefer to provide health plans to the age group of 18-65 years starting from the age of 15, because younger patients buy the policy at a lower premium fee and remain insured for a longer duration. With advancing age, the chances of acquiring an illness or disease also increases, thus making the insurance process more complex
• Pre-existing Medical Illness Or Condition: The second factor that qualifies you for a well covered health insurance plan is your overall health condition and almost all insurance providers will ask the customers to present a medical proof certifying the same. In case, the customer is over 45 years of age, he may be asked to undergo a medical examination before being accorded with a health insurance plan. Generally, pre-existing health conditions include diabetes, high bp, cholesterol, asthma, bronchitis, thyroid disease which the individual has to mention in the insurance form to facilitate suitable coverage benefits. If undeclared, the policy later can even get rejected by the company at the claim stage
• Exclusions: Certain diseases and illnesses can disqualify a customer from getting insured under the policy’s caveats and clauses. Therefore, it is advised that before buying a suitable health insurance plan for yourself or your family, please scan through the terms and conditions of the insurance policy very well

Special Eligibility Considerations

While the eligibility criteria that impact a health insurance policy in India are listed in detailed description in the above-given section but following factors briefly enumerate the special considerations for the same:

• Pre-existing Disease Or Condition: Mostly, the commonly occurring pre-existing conditions such as diabetes, high BP, cholesterol, asthma, bronchitis, thyroid disease are the pre-existing health conditions found in the list which the insured individuals declare in their medical form. Many health insurance policies have a waiting period of 2-4 years for these pre-existing illnesses however, after the waiting period, the provider is liable to pay the coverage benefits as per the T&C of the health plan      
• Waiting Period: It is basically that time duration under which a health insurance plan cannot be claimed by the insured customer. For most companies, the waiting periods usually are 30 days as the initial period; 1-2 years for specific illnesses and 2-4 years waiting period for pre-existing conditions
• No-Claim Bonus Amount: Some health insurance companies offer no-claim bonus in the form of an increased sum assured (the minimum guaranteed amount which the insurer is bound to pay to an insured customer’s nominee in the unfortunate circumstance of the latter’s demise) or reduced premium amount annually when the claim is not being filed
• Insurance Transfer: Few companies provide the insured customer facility of transferring the insurance policy to another insurer without facing implications of any changes in the existing benefits

Documentation and Proof of Identity

Once you have selected a suitable health insurance plan for purchase as per your needs and budget, the next important step is collating all the documents, filing, and submission process. Following is a list of some essential documents required to buy a health insurance policy in India:

• Age Proof: It is one of the topmost essentials in the checklist of papers to be submitted while buying a health plan and it can be provided as an aadhaar card; driving licence; 10th/12th grade marksheet; voter’s I.D; birth certificate or passport
• Identity Proof: To ensure your identity verification, you can submit aadhaar card; driving licence; Pan card; voter’s I.D; birth certificate or passport
• Address Proof: Residence proof is required to be filed and you have the options of choosing from any of the following to submit- aadhaar card; driving licence; passport; voter’s I.D; Ration card; telephone; electricity or water bill
• Medical Examination Reports: A healthcare provider can ask you to undergo a complete health check up/medical examination to disclose any pre-existing ailments and health conditions which will help the insurer to suggest the best health insurance plan for you. Therefore, the requisite lab diagnostic reports and medical certificates should be submitted when the insurance company asks for the same
• Passport-Size Photographs: Your photo proof is necessary in line with the insurance provider’s requirements’ checklist while purchasing the insurance plan

Medical History And Pre-Existing Conditions To Buy Health Insurance

All health insurance companies ask you to submit a detailed medical history before buying one. This includes the list of medications being taken by you; past history of hospitalisation and treatments received etc. The main aim behind documenting the medical history of a customer is to categorise certain ailments and medical conditions which can affect your health insurance policy as follows:  

• Waiting Period: Though it varies from one insurer to the other and one health plan to another, however most policies demand a waiting period of 2-4 years  before the customer claims their coverage in the event of him having pre-existing health conditions or ailments. During the waiting period, the insured person has to bear the cost of pre, in and post hospitalisation from their own account
• High Premiums: For any customer already suffering from certain pre-existing illnesses or conditions, the insurance providers spike up the amount on the base premium of a health plan known as loading charges to reduce their economic vulnerability
• Options Of Health Insurance Plans: Having a pre-existing illness or medical condition limits the options of available health insurance plan for you though some health plans are specifically curated to offer coverage on certain specific pre-existing diseases like asthma; Hypertension (high B.P) etc. Therefore, it is essential to accurately mention your detailed medical history along with your pre-existing conditions so that the insurer can guide you with the best healthcare plan offering lower premiums and least waiting period
• Exclusions: Few pre-existing illnesses and their associated conditions may disqualify you to avail some health insurance plans if these are mentioned under the plan’s terms and conditions disclosure. This means that you can avail coverage benefits offered under all the listed illnesses of the health plan, minus your pre-existing diseases or conditions

Common Myths About Eligibility For Health Insurance Plans

Some of the most commonly misinterpreted concepts revolving around health insurance sector are highlighted below:

1. Cheaply Priced Policies Are Better

Health insurance plans having lower premium value might seem beneficial at the onset but they provide lesser cover in terms of the illnesses and medical conditions. Thus, a prospective customer seeking value return on his health insurance investment should wisely opt for a comprehensive well covered health plan with a higher premium as per his medical requirements.

2. Young People Don't Need Health Insurance 

This is one of the most common myths that needs to be busted that younger lot of population need not be insured because an unexpected, sudden accident or illness can strike you anytime. A well covered health policy insures the youth economical financial investment on medical care and health during the early stages of their professional career.

3. Employer-Sponsored Health Insurance Is Sufficient

A health insurance policy offered at the workplace involves cost sharing between an employer and the employee which implies that the cost of the premium will be invariably deducted from your hard earned salary. Changing your employment can lead to cancellation of the health policy at the office therefore, a personally procured health insurance policy is necessary for security against unforeseen job and health challenges.

4. No Coverage If Hospitalisation Period Is Less Than 24 Hours

A lot of health providers in India are now incorporating insurance plans that offer you cover for medical services and treatment procedures that last for less than 24 hrs for eg. - Dialysis, angiography, tonsillectomy, chemotherapy etc

5. Health Insurance Covers All The Medical Expenses 

Most people assume that buying a medical insurance plan alleviates the financial toll on their pockets by covering all healthcare costs but it’s only a myth because every policy has its terms, conditions and exclusion caveats against which the benefits are earned. Like in case of deductibles and co-payment clauses, the insured customer is required to pay a portion of the medical expenses while the rest of the amount is settled by his cover plan.  

Conclusion

A health insurance policy usually covers medical expenses, pre-hospitalisation and post-hospitalisation, domiciliary expenses, ambulance charges, room rent, ICU charges, and medicines. There are some common eligibility criteria for these health insurance policies as mentioned above but there are some special ones and it is recommended that you read the description carefully for those special points.

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

FAQs

Ques 1. Can we add family members to our existing health insurance plan?

Ans. It depends on the terms and conditions of the provider company as it should be mentioned in their provisions whether family can be added and if so, then up to what age limit.

Ques 2. Are pre-existing conditions/diseases covered under a health insurance plan?

Ans. Offering medical coverage benefits in cases of an existing illness/condition reported by a customer is subject to underwriting clauses and waiting periods which differ from one illness to the other.