Health cover doesn’t fit the ayurveda bill

Are you suffering from diabetes, arthritis or any other chronic disease and opting for ancient forms of medicine? The good news is insurance cover is available for such patients. After some insurance companies began recognizing ayurvedic treatment, many are going ahead with cashless transactions or 80% reimbursements for chronic diseases. Not just that, Karnataka has recognized 15 ayurvedic hospitals for its employees who can undergo treatment and even claim reimbursement.

The Ayush department is in the process of drafting specifications of ayurvedic treatments that can be reimbursed like any other mainstream one. "This can help employees get treated anywhere they like," said Ayush director G N Srikantaiah.

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It is also evolving standards for alternative medicine hospitals so that they can be covered by private insurance companies.

But ayurvedic hospitals feel private insurance companies are still restrictive in terms of coverage. At Soukya holistic health centre in Whitefield, 25 cases of 80% coverage have been made after some insurance companies began covering alternative medicine. "It was a little tough as the parameters of our treatment do not match that of mainstream medicine and diseases. Neither do we have standard pricing. But nowadays, people are coming to us for long-term chronic diseases that could cost up to Rs 1.5 lakh. These are comparable to surgeries in English medicine," said Dr Isaac Mathai, director of Soukya.

Soukya is in the process of getting a certificate from the National Accreditation Board for Hospitals and Healthcare Providers (NABH), so that the process of insurance coverage becomes smoother. At Soukya, the diseases mostly covered by insurance are chronic longterm conditions like arthritis , spondilytis, neurological diseases and even cancer. "Anything chronic should be covered by health insurance providers ,'' added Dr Mathai.

Insurer cannot arbitrarily refuse policy renewal

Healthcare is costlier than a stay in a five-star hotel. Clearly, it is beyond the means of the common man. One-time hospitalization can wipe out a lifetime's savings. So, mediclaim policy, as a welfare measure to bring the cost of decent healthcare within the reach of the average citizen, was introduced. Yet, insurance companies, which willingly accept premium year after year, are reluctant to settle legitimate claims. They look for excuses to reject these.

Often, insurers arbitrarily refuse to renew a policy, when it becomes evident that the claims ratio would go up. This, clearly, is not permissible, as held by the Supreme Court in the case of Biman Krishna Bose versus United India Insurance & Anr.

Biman Bose and his wife, Alka, had a mediclaim policy with United India Insurance. Alka fell ill, and was hospitalised. After discharge, a claim was made for reimbursement of expenses, amounting to Rs 8,243. Although all the necessary documents were submitted, yet even this meagre claim was not settled. This, despite repeated reminders.

So, the insured filed a complaint before the Kolkata district consumer forum. The ding-dong legal battle spanned four years and four tiers of courts till the Supreme Court finally intervened, directing the insurer to pay the claim, as also awarding Rs 20,000.

One would have expected the matter to have concluded here. But, unfortunately, when the policy became due for renewal, the insurer refused to renew in vengeance.

Once again, the insured felt compelled to take legal action. A writ petition was filed in the Calcutta high court, and the second round of battle ensued.

The High Court allowed the writ, set aside the insurer’s refusal, and directed the policy be renewed.

The insurer, however, contended the policy had lapsed, as, during litigation, the renewal premium had not been paid. So, the division bench, while agreeing with the view taken by the single judge, directed the insured to subscribe to a new policy, holding that renewal was not possible.

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This order defeated the very purpose of litigation, because, in case a fresh policy is taken, all pre-existing diseases are excluded. Also, claims in respect of certain diseases contracted within the first 30 days of the new policy are excluded. So, Bose appealed to the Supreme Court (SC).

The SC observed the insurer is bound to act fairly and reasonably. Renewal cannot be refused on irrelevant and extraneous considerations, or in an arbitrary manner. Refusal to renew merely because the insured had approached the courts against the rejection of the claim is not justified.

The SC further observed the initial renewal premium had been paid by the insured, but wasn’t acknowledged by the insurer. Even during the intervening years of litigation, there arose no occasion to deposit the premium.

Accordingly, it held the refusal to renew as unfair and arbitrary, and directed the policy be renewed from the date it fell due for renewal.

It also ordered to further renew the policies for the subsequent expired years, if the premium had been paid. The insured was also awarded costs of Rs 5,000.

Since then, the SC has now held that refusal to renew a policy amounts to victimisation, unfair practice, and high-handededness.

Health expo to unveil low-cost medical equipment

The Indian healthcare sector has emerged as one of the most progressive and largest service sectors in India. The public sector however is likely to contribute only around 15% to 20% of the required $ 86 billion investment.

"The corporate India is, therefore, leveraging on this business potential and various health care brands have started aggressive expansion in the country," said Dr EV Ramana Reddy, secretary to the department of Health and Family Welfare, at the inauguration of a three-day long exhibition, Healthex, on Friday.

“Various state governments are collaborating with the private sector through PPP to improve efficiency and decrease the inequity in the health system. Community health insurance initiatives have also been undertaken in terms of Yeshaswini Scheme in Karnataka,” said Dr Reddy.

The country's vision 2020 should include the delivery of affordable healthcare system even to the rural people. Preventive healthcare is another aspect that should be focused on and doctors should gear up to educate patients, he added.

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On the healthcare development in Karnataka, he revealed that the healthcare landscape is changing rapidly with corporate and foreign hospitals setting up centres to offer high quality healthcare. Moreover, the government is also promoting India as the global healthcare destination to offer holistic treatment. Now, private and public hospitals need to synergise their efforts to promote India as the healthcare destination worldwide, said Dr Reddy.

The Indian healthcare industry is undergoing a rapid expansion and in order to survive the healthcare market competition and growth, hospitals are continuously updating themselves on current issues, challenges, and the best methods to reach out to and serve their patients better, he said.With several innovations in the healthcare sector, there is a need for both private and public sector to work jointly.

"The rapid technical changes in the recent past and the commitment of the Army Medical Corps Services to provide a cradle-to-grave service have encouraged diversification in the unexplored fields in military medical services,” said Air Vice Marshal Pankaj Tyagi, principal medical officer, Headquarters Training Command, Indian Air Force.

Rs.150-cr for new insurance scheme

A sum of Rs.150 crore has been allotted initially against newly-formulated Chief Minister's Comprehensive Health Insurance Scheme, Finance Minister O. Panneerselvam announced in the Assembly on Thursday.

The old insurance scheme of the DMK regime was terminated, but to benefit patients in the bridge period between suspending the old scheme and launching the new one, a sum of Rs.100 crore was separately allocated, Finance Secretary K. Shanmugam said in his post budget briefing.

The government will focus on improvement of primary health care facilities in urban areas. The 60 centres already sanctioned under the National Rural Health Mission, will be shifted under the administrative and technical control of the Directorate of Public Health. Further, the Finance Minister announced that Urban Primary Health Care centres will be set up in 75 more small urban towns. A super-speciality centre, at a cost of Rs.100 crore, would be set up in Annal Gandhi Government Hospital, Tiruchi.

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Additionally, infrastructure and equipment upgradation has been planned for district hospitals and poison treatment centres at a cost of Rs.55 crore, under the Tamil Nadu Health Systems Project. Also, under public-private partnership agreements, diagnostic facilities at the major hospitals will be improved, and state-of-the-art computer aided laboratories established in all districts in a phased manner. A ‘Hospital on Wheels' scheme will be launched to provide door-to-door health care services far-flung areas to begin with. Sanitary napkins will be provided free of cost to rural girls through the ICDS network and village health nurses. A sum of Rs.46 crore has been provided for this.

Emergency transportation provided through the 108 ambulance service will further be extended to offering inter-facility transfer for all emergencies. Additionally, special vehicles will be put into service in tribal and hilly areas, and one vehicle will be provided per district for transporting new born babies.

IndiaFirst Life forays into health insurance

IndiaFirst Life Insurance on Wednesday forayed into the health insurance segment by launching a new product and said it expects to garner about 10 per cent of its total premium within next three years.

The company, a joint venture between public sector lenders Bank of Baroda and Andhra Bank along with UK-based investment firm Legal & General, also said it aims to sell at least 1 lakh health insurance policies within that period.

"As a line of business, health offers the best potential in the insurance sector. We have today launched out first plan -- IndiaFirst Money Back Health Insurance Plan -- and in the coming days, we will come out with more offers," IndiaFirst Life Insurance Managing Director and Chief Executive Officer P Nandagopal said.

The Money Back Plan would offer protection to customers for up to 10 years. The minimum premium payout of the customer would be Rs 10,000.

The health insurance cover would be a minimum for Rs 1.5 lakh and maximum of Rs 10 lakh.

"Health insurance, along would pension and micro- insurance, would be our three focus areas and we expect 10 per cent of our total business to come from health insurance within three years," Nandagopal said.

We also aim to sell at least one lakh health insurance policies in next three years, it added. The plan would offer health cover as well as savings option to the customer.

A part of the premium, depending on the age and health of the customer, would be credited into the buyer's policy account and this money would be invested in various funds to get optimum returns.

"The plan offers a comprehensive health cover for the entire family along with the investment flexibility to grow wealth by investing in different funds under a single plan," Nandagopal said.

"Our aim is to grow by 40 per cent year-on-year and be among the top six players within three years in the life insurance segment," he said.

IndiaFirst Life Insurance, which started operations in March 2010, currently has total premium of over Rs 1,000 crore.

A large population is without health insurance, as the industry has reached only 4.22 per cent of Indians. Around 14 crore people in urban areas remain untouched by any form of health insurance.

Choose your health cover with care

Check for renewal ceasing age, co-pay norm and sub-limits before opting.

A health insurance policy is a ‘must-have’ according to financial planners. Yet, picking up the right health insurance is not an easy task, given that there are 23 health insurance companies. Consider the six to eight life insurers offering health benefits and customers can be spoilt for choice.

While cost is certainly a deciding factor when choosing a plan, here’s a checklist of what else to consider.

Renewal ceasing age: Customers buying insurance rarely look at the age of policy renewal. The renewal ceasing age is the one when the insurer, no matter how long you have been with it, will refuse to renew your policy. For instance, health policies from ICICI Lombard cease at age 70.

Obviously, the higher the renewal ceasing age, the better. Most companies now offer higher or even lifetime renewal policies to customers.

Co-pay options: Typically, as health risks rise with age, companies ask customers to chip in. Besides higher premiums, customers may also have to co-pay for the policy. Companies follow different parameters to decide when they will convert the policy to a co-pay scheme.

For instance, Star Health Insurance begins co-pay once the renewal ceasing age sets in. So, customers could extend their period of coverage by changing their existing plan to a co-pay scheme. Bajaj Allianz General Insurance asks to co-pay if the customer goes to a non-network hospital.

Exclusions and PEDs: These two factors are the most painful ones. An exclusion is a statement in an insurance policy which describes a condition or type of loss not covered under it. Like, hospital cash plans do not cover dental treatment or surgery, pregnancy-related treatment, childbirth and so on.

KG Krishnamoorthy Rao, MD & CEO, Future Generali General Insurance, says, “Check for the coverage in terms of the inclusions and exclusions. These are mentioned in the policy brochure. And, if it does not cover something, you can either opt for other plans or take a rider.”

Another important feature, pre-existing disease (PED), may or may not be covered in health policies. PED is an illness or medical condition diagnosed prior to buying the policy. Nowadays, most companies cover PED with a lag of two to four years.

Sometimes complications arising from already existing diseases may also not be covered for the first four years of the policy. Senior citizen health plans exclude many ailments and, in many cases, need to be topped up with a rider.

Sub-limits: Check, Krishnamoorthy warns, to check for the limit on payments against the health plan. Health insurers reimburse those expenses that have been incurred reasonably. This is one way for insurers to restrict payments, especially when they think there is overcharging by hospitals. Typically, policies have a cap on the hospital room rent, operation theatre, ambulance charges and so on. For instance, ambulance charges on Bajaj Allianz Health Guard are only up to Rs 1,000.

All other charges, too, are reduced in proportion to the room rent cap. This is primarily because the charge structures levied by hospitals varies by the type of room chosen by you. But insurers are trying to do away with it. ICICI Lombard Family Protect Premier does not have sub-limits or a cap on room charges.

Policy issuer: According to health insurance experts, there isn’t much to debate here. “A traditional plan from health insurers should be the first medical policy that you buy, as these are exhaustive. Those from a life insurer can be an additional buy,” says Mahavir Chopra, head of e-business and retail, Medimange.com.

Traditional policies from health insurers or indemnity plans settle claims on a cashless basis or they may reimburse your bills. Life insurers who offer benefit plans or Hospital Cash Benefit Plans pay a fixed amount as soon as the illness is diagnosed.

Policies from life insurers offer restrictive covereage. They also have limits on the amount paid per day and the number of days the benefit can be availed. Say, you are supposed to be paid Rs 25,000 for a surgery; you will get it. But if the actual expense rises to Rs 40,000, you will bear the extra Rs 15,000.