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If you're banking solely on the health cover provided by your employer to take care of your and your family's insurance needs, it's time to change the strategy. You will have to beef up your insurance portfolio with an individual policy as group policies offered by employers are slowly undergoing a transformation.
Restrictions, such as those on room rent and sub-limits on claims, which were a part of individual mediclaim policies so far, are slowly being incorporated in group insurance covers too.
The employers are reducing benefits because the premium they have to pay has shot up by 30-100% due to rising claims. KG Krishnamoorthy Rao, MD and CEO, Future Generali India Insurance , says, "The premium has gone up by 15-20% annually, and for some corporates it has risen by 100% where the claims have been 200% (of the premium paid)." To cut down the premium, corporates are negotiating with insurance companies on lower coverage areas and ways to restrict claims.
The good news is that so far no company has refused to pay the rising premium. However, as they are curtailing benefits, you should know what you stand to lose and the areas you might need to cover through an individual policy. Here are some ways that your mediclaim policy may be tweaked.
Parental coverage
Your employer may refuse to cover your parents in its group insurance policy. Sanjay Datta, head, customer service, at ICICI Lombard General Insurance Company , says, "Several companies are considering options on how dependants can be covered. Some have issued a separate policy, where the premium is borne by the employee."
In some cases, if the parents are covered by the policy, the employee may have to pay for a part of the expenses. "Fewer companies are providing a cover for dependants, and if they are, there is a co-pay clause of 5-30%," says Pavanjit Singh Dhingra, vice-president at Prudent Insurance Brokers.
Hospital network
From now on, you won't be able to walk into any hospital and ask your employer's insurer to reimburse all your medical expenses. Most insurers are restricting the network of hospitals you can access. In case of some hospitals, you will be able to claim only a certain amount.
Rao says, "If employees favour certain hospitals when there are other, equally good ones, we ask for co-payment. This compels the employees to evaluate whether they really need to go to an expensive hospital or opt for the other one, especially if the treatment is for a minor disease."
"There are two types of networks for hospitals-the preferred provider network (PPN) and the regular network. Insurers fix a rate for hospitals within the PPN, but if you go to a hospital beyond this network, you will have to either co-pay or pay a higher premium. Most corporates are opting for the PPN so that they can pay a lower premium," says Vimal Goyal, national head, corporate business, SMC Insurance Brokers . Another option that the employers are considering is replacing expensive hospitals in the network with comparatively cheaper ones. This reduces the cost of claims under the group policy.
Disease-wise restrictions
Insurers are now fixing limits on the amount you can claim for some diseases. Goyal says, "There are disease-wise sub-limits now. So, for an angiography, a public sector insurance company will pay a maximum claim of Rs 23,000 if the sum insured is Rs 1 lakh, while for angioplasty (and the same amount of cover) it will pay only up to Rs 75,000. For cataract operations, most insurers are permitting a claim of only Rs 20,000." Obviously, you will have to fund the rest of the expense yourself.
Other limitations
Insurers are taking other drastic measures too. "Some companies, which are witnessing a high claims ratio, are planning to do away with the cashless facility completely," says Dhingra. In select cases, co-payment of 10-20% is applicable to the entire group. Also, be prepared for your medical cover to shrink this year. "Companies that had increased benefits, such as higher covers, last year are reducing them this year. Room rent restrictions that were not a part of group covers earlier are now being included," adds Dhingra.
Claim submission
Insurers are also getting strict about the submission of documents. "If the documents for reimbursement claims, which are 25-30% of the cover, are being submitted 30 days after the discharge from the hospital, the claim could be rejected," says Goyal. So, go through your policy carefully and mark all such important information so that you do not lose out on even the few benefits that are available to you.
Should you take a separate cover for your parents under the group policy scheme? No, it's best to buy an individual policy for them. Shreeraj Deshpande, head, health insurance, Future Generali India Insurance, says, "In the long run, separate covers for dependants, where you pay the premium, won't work. The employees who have healthy parents would cover them in the first and second year. Later, the premium is bound to keep increasing due to the parents of those employees who may not be in good health. So, even if your parents are fit, you might end up paying a higher premium." This is why it makes more sense to pick a fresh policy.
