15 Essential Questions to Ask Your Health Insurance Agent

The process of selecting a health insurance policy involves many factors, for example, limits, exclusions, waiting periods, and benefits included in the health insurance policy. Asking the correct questions is key at this time. The discussion with your health insurance agent prior to purchasing the desired product will help you get more information concerning the policy and its suitability for you. Let us understand what questions to ask before buying health insurance.

What is the importance of asking the right questions before buying health insurance?

The common practice of comparing health insurance plans purely by way of their premiums is not right. Lower premiums can mean restrictions in terms of coverage, longer wait times, and a less extensive network of hospitals. The seemingly low premiums might end up becoming expensive at the time of claims. Getting your health insurance policy right involves the following:

• Knowing the exact coverage you want
• Saving yourself from surprise expenses at the time of hospitalisation
• Ensuring that you get the right cover as per your health and finances
• Taking care of your family’s needs as well It does not matter whether you’re getting a new health insurance policy or are changing providers during renewal; interacting directly with an insurance agent goes a long way.

What questions should you ask your health insurance agent before buying a policy?

Scope of coverage, waiting periods, sum insured, room rent limits, sublimits, and information about the network of hospitals are some important questions to ask your health insurance provider.

1. What are the things covered by this policy, and what aren't?

This is the most important question. You should always know what is covered by your policy and, even more important, what isn't covered. Many health insurance policies exclude certain treatments and procedures, and certain illnesses in the case of pre-existing conditions, for a defined number of years.

2. How long is the waiting period for pre-existing conditions?

In the case of pre-existing conditions like diabetes, high blood pressure, or thyroid disorder, ask your agent how long you'll need to wait until coverage becomes available for the treatment. The waiting period may vary between one year and three years.

3. How much is the sum insured? Is it enough?

Not everyone needs a high sum insured. Ask yourself what the appropriate sum insured is for you. It should be enough to cover you in case of any medical emergency.

4. What is the room rent limit, and how does it affect my claim?

Room rent caps are one of the most overlooked policy features. If your policy has a room rent limit and you choose a room above that limit, the insurer will proportionately reduce your entire claim, not just the room rent component. Ask your agent to explain this clearly with an example.

5. Are there any sub-limits on any particular treatment?

There could be limitations on the payout on some of the treatments, like Cataract Surgery, Knee Replacement, and Maternity Cover. Ensure that you get your policy document to get all the information regarding the same, rather than ending up in a hospital bed.

6. What is the network hospital list, and are my preferred hospitals listed?

Please note that you can avail yourself of cashless hospitalisation only through network hospitals. Your agent can supply you with the list of hospitals in its network, and check whether hospitals around your home and office premises are on that list.

7. What is the claims settlement ratio of the insurer?

Claims Settlement Ratio refers to the number of claims resolved by the insurance firm in the previous year. It is measured in percentage. The higher it is, the better. Make sure to ask your broker about it, along with the reasons for claim denials.

What questions to ask about policy flexibility?

Plan upgradability options, portability guidelines, grace period, policy renewal rules, and family floater benefits are some flexibility-related questions to ask when looking for health insurance.

8. Can I upgrade my sum insured upon renewal?

As you age, your requirements in terms of health also change. Therefore, find out if the policy lets you upgrade the sum insured at the time of renewal without subjecting you to more medical tests and new waiting periods.

9. Can I include other family members in the policy later on?

If you currently buy an individual policy, but there is a possibility that you will be getting married in the coming years and having kids, find out if you can easily turn this individual policy into a family floater later without buying a new policy.

10. Is the policy portable?

With health insurance portability, you can switch insurance companies while retaining the waiting period credits already built up in the previous policy. Find out if the insurance company offers you the option of portability.

11. What would happen if I failed to pay the premium when it is due?

Find out the renewal grace period and the fate of the waiting period credits in case of any lapse in premium payments.

12. Does the policy have lifetime renewability?

This is a crucial issue in terms of older customers who might buy insurance policies. The reason behind this is that there can be an upper limit on the age at which policies can be renewed.

What questions to ask about additional features and health insurance benefits?

It is wise to ask questions about daycare procedures, OPD coverage, maternity benefits, AYUSH treatment, and mental illness coverage before deciding on the insurance plan. This helps you get a better understanding of its benefits.

13. Does the policy cover daycare procedures?

Today, many treatments no longer require a 24-hour hospital stay. Ask whether daycare procedures are covered and request a list of covered procedures.

14. Is the outpatient department (OPD) covered under the policy?

Consultations with doctors, diagnostic tests, and prescription charges become quite expensive over a year, even if there is no hospitalisation. You must ask if OPD costs are included in the plan.

15. Is there any coverage for maternity and infant costs?

For those who intend to grow their families, this is one important question. There are always waiting periods of between one and three years when it comes to maternity cover, which makes it necessary to purchase insurance sooner.

Bonus questions and discussion

Knowing the claim procedure, contact person, common claim rejection reasons, and steps for cashless and reimbursement claims is essential before purchasing any health insurance plan.

1. What are the procedures for making a cashless claim?

Find out about the cashless claims process from the time that you report the claim to your insurer till the time you get discharged from the hospital and your claims are settled. Also, find out how fast is the process of pre-authorisation generally.

2. What is involved in the reimbursement claim?

You have to make payments on your own at the time of treatment at hospitals that are not in network and later claim reimbursements. Inquire about the necessary documents, the time taken, and the reasons due to which claims could be delayed or rejected.

3. Who is the contact person for claims?

It is essential to know who to reach out to in case of any queries regarding claims. It is essential to know who will assist you in case of a medical emergency.

Apart from the usual questions, here are a few things that you should discuss with your agent before finalising your health insurance policy.

Difference between individual cover and family floater

Family health insurance plans have only one sum insured covering all family members. In case one family member files a large claim, then the sum insured left for the other family members goes down. For families where some members have high-risk factors, individual policies could be considered.

• Inquire about top-up and super top-up
• If the sum insured in the basic policy is insufficient but increasing the premium amount is unfeasible, you should ask your agent about top-up or super top-up options. They will only become active once the deductible amount is reached.
• Read through the policy document

Health insurance terms and conditions

Ask your agent to explain the important clauses in the policy document. Brochures always have the positive aspects highlighted, while the policy document itself is the legally binding one.

Frequency of renewal and changes in premiums

The insurance company revises premiums from time to time so check for frequent and/or drastic changes, and what circumstances can affect premium changes during renewals.

Conclusion

Purchasing the right health insurance plan requires considering factors like age, health condition, family status, and financial capabilities. There is no other way but to ask the right questions in order to purchase the right plan.

There is no need to be pushed by the insurance agent to make a choice. On the contrary, an experienced and reputable health insurance agent would encourage you to ask any number of questions in order to find the best plan that would suit you.

Take the list of questions provided in this guide as a starting point. Ask every question to your health insurance agent. If you get unclear responses, treat it as a red flag. The time you invest in asking questions now can save you considerable stress, confusion, and expense when it matters most, at the time of a claim.

Frequently asked questions

Is there insurance coverage for mental illnesses as well?

Under IRDAI norms, it is compulsory to offer mental health coverage; however, it is not mandatory that all types of mental health disorders be included. One must ask specifically about coverage, as well as whether there is any limit on the same.

Is there any cover for AYUSH treatment?

A lot of people opt for alternative modes of treatment. It is important to enquire whether AYUSH treatment comes under the scope of the policy.

What are the most common reasons for claim rejection?

This is perhaps the most essential question you should ask your health insurance company. An honest broker will brief you on the common mistakes that result in denials, such as non-disclosures of pre-existing diseases and treatment in hospitals outside your network. Additional considerations

Disclaimer: The information shared in this blog is intended solely for general awareness and should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare provider for personalised recommendations and care.