Senior Citizen Health Insurance Plan: Coverage, Claim & Exclusions

Updated: 31-08-2023 06:32:27 AM

A sudden medical emergency clubbed with rising treatment costs can lead to financial problems, if an arrangement is not made in advance. Such a situation can arise in anybody’s life, including senior citizens. To tackle such a situation, and to stay away from any debt trap due to medical emergency, elderly people can opt for a senior citizen health insurance.

What is Senior Citizen Health Insurance Plan?

A senior citizen health insurance plan is specifically designed to provide financial aid to people over 60 years of age. It helps them to meet their sudden medical needs. All health insurance companies in India offer health plans to this particular segment to make them financially secure. These plans cover medical expenses incurred in the treatment of specified illness, disease, injury or hospitalisation within or outside the country.

What Senior Citizen Health Insurance Covers?

The insurance companies in India offer various types of senior citizen health insurance plans. The coverage offered differs from one plan to another. Following are some of the coverage provided under the Senior Citizen Health Insurance Plan:

• Hospitalisation and medical expenses: Health plans for senior citizens cover all sort of medical and hospitalisation expenses incurred due to the treatment of listed illness, disease, injury or health condition. Medical expenses also include room rent, fees of the doctors/ specialists/ physician, OT charges, costs of medicines and drugs, etc. These expenses are usually covered up to the limit of sum insured amount chosen
• Pre- and post-hospitalisation costs: Most of the health plans designed for senior citizens cover the medical expenses incurred before and after hospitalisation. Each plan has its own specific time and coverage limit for such expenses. Many plans cover 30 days of pre-hospitalisation and 60 days of post-hospitalisation expenses, while for some, it is 60 and 90 days respectively
• Pre-existing diseases: After a specific waiting period, certain pre-existing medical conditions can be covered. So, you should thoroughly read the prospectus before buying a plan
• Day care procedures: There are a number of health plans for senior citizens that cover the expenses incurred in day care procedures. To put it simply, day care procedures do not need 24 hours or more of hospitalisation, such as in chemotherapy, dialysis, etc.
• Home treatment: With some senior citizen health insurance plans, the insured can get coverage for treatment at home. This makes it easier for elderly people to get the treatment without going through the pain of travelling to the hospital if they are not in a condition to do so

How Senior Citizen Health Insurance Plan functions?

• Evaluate the need and requirement of the senior citizen after analysing the health situation
• Buy the most suitable plan after checking and comparing the policies and premium
• In case of any hospitalisation or treatment or day-care need, use the services of a network hospital under your insurance company
• Provide the health card and other required documents to the TPA desk of the hospital
• After a survey, the medical bill is directly paid to the hospital in case of cashless claims
• For reimbursement claims, provide the required documents and the medical bills to the insurance company and you will be reimbursed for it later by the insurance company

Types of Senior Citizen Health Insurance Plans

A senior citizen health insurance plan is of 2 types.

1. Individual plan: An individual health insurance covers unforeseen medical expenses up to a certain limit for the policyholder.
2. Family floater plan: A family floater health insurance plan helps the policyholder and the entire family meet unforeseen medical costs.

Eligibility Criteria

Claim Process  

In case of any eventuality, you need to timely file the claim with the insurance company. You should also be aware of the claim process so that you do not miss any important point in order to get a hassle-free claim. A health insurance claim is of 2 types – cashless, where the insurance company pays for the medical expenses, and reimbursement, where the insured makes the payment which is later reimbursed by the insurance company. Let us understand the process.

• On hospitalisation, inform the insurance desk of the network hospital
• Provide your health card at the desk
• Hospital needs to submit the pre-authorisation form along with the doctor’s approval to the insurance company
• After scrutiny of the submitted documents, if the insurance company approves the claim, it will process the payment to the hospital
• In case there is any issue, the company might ask for other documents
• In case you are not using a network hospital, make the payment yourself
• Then submit the required documents along with the claim form to the insurance company
• After a scrutiny, the company will make the payment to you as per your sum insured limit

Documents Required for Claim Process

The claims process for senior citizens health plans is comparatively easier and hassle-free. In case of medical emergency or a planned hospital visit, the insurance company should be informed about the incident. Below are some of the documents to be submitted to the insurance company for a timely claim process. The items on the list may vary for different companies.

• Duly filled in and signed claim form
• Policy health card
• Medical bills and receipts
• Detailed medical reports and prescriptions
• Diagnostic test reports

Time Taken to Settle Claims

While filing a claim when needed, follow the correct procedure and submit all the required documents for timely claim settlement. As per the IRDA, a senior citizen health insurance plan should be cleared within 30 days from the day of submitting the required documents. In case of any further investigation, the time duration can go up to 45 days.

Also Read: Oriental Health Insurance Health of Privileged Elders

Exclusions 

There are certain cases for which an insured person cannot make claims. These are called exclusions. These cases may vary from one health policy to another, but the following are some common exclusions under a senior citizen health insurance plan

• Medical and hospitalisation expenses arising due to the treatment of pre-existing diseases, illnesses or injuries before the completion of the waiting period
• Cost of cosmetic surgery, aesthetic or plastic surgery
• Treatment or hospitalisation expenses due to drug or alcohol abuse
• Expenses incurred due to dental surgery or treatment
• Cost of contact lenses, spectacles and hearing aids or devices
• Some health plans cover the expenses related to non-allopathic (Ayurvedic, homeopathic, Unani, etc.) treatments, but usually they are not covered under the health plans designed for senior citizens
• Cost incurred due to treatment of sexually transmitted diseases like HIV or AIDS

Important Aspects

A health insurance plan for senior citizens helps elderly people meet various emergency medical expenses. Looking at a plethora of senior citizen health plans available in the market, it makes sense to consider certain aspects before buying one either for yourself or for your parents.

• Plan Type: Both individual and family floater health plans are available for senior citizens. You can opt for individual senior citizen health insurance plans, as they offer more coverage
• Coverage: Another important point to keep in mind while buying a health plan for senior citizens is the coverage provided. For senior citizens, a comprehensive coverage is better. After a certain age, people are more likely to fall ill and thus, need more medical help. A health plan with higher coverage will help the insured get good medical facilities without worrying about the expenses
• Waiting Period: The waiting period of a health policy restricts the policyholder to avail the benefits attached for a certain or pre-defined period of time. Thus, the coverage is provided after the completion of the waiting period. This is particularly the case with pre-existing health conditions, illnesses, diseases or injuries. So, it is suggested to choose a health plan for senior citizens that has a lesser waiting time
• Co-Payments: Some insurance companies have a co-payment clause in their health insurance policy. This means that a certain part of the claim will be borne by the policyholder, while the rest will be settled by the insurance company. This way even if the health plan is affordable, one may not be able to maximise the coverage benefits
• Illnesses/ Diseases Covered: Thoroughly check the policy for the number of illnesses, diseases and injuries covered in the health plan before buying. Try to compare more plans and pick the one that suits and provides comprehensive protection or coverage against maximum illnesses, diseases or ailments
• Hospital Network: Always choose a health plan that has an extensive network of hospitals in India as well as abroad. This will help the insured avail medical attention with ease along with cashless claim payment facility

Advantages of Senior Citizen Health Insurance Plan

Falling ill is obvious with growing age. Thus, a senior citizen health insurance plan will ensure that all the medical expenses of elderly people are taken care of when needed. Below are some of the advantages of having a senior citizen health insurance plan.

• By meeting any emergency medical and hospitalisation expenses, the health insurance plan helps senior citizens to stay away from any financial burden and debt trap
• It offers cashless facility at network hospitals, thus, you don’t need to worry about any payment (apart from co-payment) during hospitalisation or any other treatment
• Annual health check-ups help in knowing any upcoming threat
• Pre- and post-hospitalisation cover becomes a big monetary help for elderly people when the sources of income might begin to reduce
• Premium payments offer tax exemption up to Rs 50,000 under Section 80D of the Income Tax Act, 1961

FAQs

Q1. Is the senior citizen health insurance plan portable?

Yes, it comes with the portability feature wherein, you can change the insurance company or the policy. For this, formally inform the company in advance before the renewal date.

Q2. Is a medical examination needed for buying a health insurance plan?

People above 45 years of age need to undergo a medical examination before buying a health insurance plan.

Q3. Who pays for the medical examination done before buying a health insurance plan?

The examination is usually done at a testing lab that has a tie-up with the insurance company. So, the insurance company pays for the examination.