I am going to rant a little today but trust me this is for your own good because I'm genuinely tired of seeing people proudly say that Shashank I have a health insurance and then quietly pay lacks of rupees from their own pocket inside the hospital. Just yesterday someone told us we had insurance cashless also still had to pay 1 lak rupees ourselves and that's exactly the problem. If you had insurance and still paid that much, then you didn't buy actual protection.
You bought a plan without research or expert guidance. And this is what people don't realize. Out of pocket in health insurance simply means money that goes from your bank account instead of the insurers.
Now, 40% of people who have insurance still end up paying out of pocket. And sorry folks, but that is just stupid. This doesn't happen only in reimbursement claims.
It happens even in cashless ones. Cashless just means the insurer coordinates with the hospital. It does not mean zero payment.
If your policy has gaps, you will still end up paying and you will pay a lot. Trust me. See, the first big reason this happens is deductibles.
This is very common in top-ups and super top-up plans. A deductible, if you don't know yet, is the amount that you must pay first before the insurance kicks in. So, if your deductible is three lakh rupees and your hospital bill is 6 lakh rupees, the insurer will pay only the remaining three.
If you don't have a base policy or employer cover to absorb that deductible, that money comes straight from your pocket. The second reason is co-ayment. Copay means that you agree to pay a fixed percentage of every claim.
10, 20, sometimes even 30%. So if your hospital bill is 5 lakh rupees and you have a 20% copay, one lakh is automatically deducted. Senior citizen plans are notorious for this and most people don't even realize that they have a copay until they make a claim.
So please, please avoid plans with copay. Don't try to cheap out on 2,000 rupees and end up buying a substandard plan and ending up spending 1 lakh rupees in the bill. Okay, now comes the biggest villain and the most misunderstood one.
Room rent limits. Let's say your policy allows a room rent of 5,000 per day, but the hospital room costs 8,000 rupees. What many people don't realize is that insurers don't just cut the room rent difference.
That's 3,000. They apply something called as proportional deduction. That means doctor's fees, nursing charges, OT charges, everything gets reduced in the same ratio.
Suddenly a small room upgrade turns into an out- of-pocket expense of 1 lak or more. So please choose a policy without a room rent limit so you can be stress free. And yes, if you are confused where to look for such clauses, then take a minute and book a free call with us.
The link is in the description. There will be no pressure at all. Just honest advice from our ID certified experts.
Links in the description. Okay, moving on. Then there are consumables and non-medical expenses.
Things like gloves, syringes, PP kits, gauze, masks, nebilization kits. Now, hospitals do use them, but insurers often don't pay for them unless you have a specific add-on. These items alone can form 5 to 15% or even 20% of your total bill.
So, yes, your claim might be approved, but you still end up paying tens of thousands because your policy didn't cover these basics. Moving on, another big reason for out-of- pocket expenses is waiting periods and exclusions. Now, the first 30 days of any health insurance policy don't cover any illnesses, just accidents.
Pre-existing diseases come with waiting periods from either one to three years. Specific surgeries like hernia, catact which are slow growing have their own waiting periods and can be anywhere between 1 to two years. So if you claim during these phases, insurance won't pay and the entire bill becomes out of pocket.
People call this insurance fraud, but it's actually just unrefined print. So always wise to get your insurance early and waiting periods get over sooner. Next, if your policy lacks a broad pre and post hospitalization, then you'll likely pay for diagnostics and physotherapy sessions out of your own pocket.
And trust me folks, they're not cheap. The simple thumb rule is to look for minimum 60 days prehospization coverage and 90 days post hospitalization coverage. Now, finally, please start off with a high sum in short.
During our advisory, we say that you should try to get a plan for which you can afford to pay premiums for two main reasons. This eliminates the need for a super top up in future. Thereby you don't end up paying for a deductible and with cumulative bonus you can keep growing your summon short.
If you're in a tier 1 city 15 to 20 lakh should be a good start. If you're in tier 2 or three then 10 to 15 should be a good spot. Choose plans with no room rent limit.
Avoid copay clauses unless you absolutely have no other option. Add a consumable or non-medical cover. Make sure your summon shot is realistically high.
Use super topups smartly with a base policy or employer cover to handle the deductible and most importantly buy early so waiting periods are already over when you actually need to make a claim. So here is my final ask. If you don't want to curse your insurance policy while sitting in a hospital corridor, if you don't want surprise bills after a so-called cashless claim, and if you want your insurance to actually do its job, Dr to either book a free call or a free chat.
Get unbiased advice. If your policy is already good, we'll tell you that it's enough. But if there are any loopholes that you should know about, we'll tell you up front.
Folks, spend your money on life, not on fixing insurance mistakes later. I'll see you in the next one. Until then, happy insurance hunting.
