Coverage Of Senior Citizen Health Insurance Plan Scheme And Exclusions Of Claim
Coverage Of Senior Citizen Health Insurance Plan Scheme And Exclusions Of Claim.Since people grow old they are most likely to incur huge bills on medical facilities and common diseases are more likely to attack older people. Health insurance plans for senior citizens can be defined as being insurance products that are meant to cater for the senior citizen’s health needs to make health care accessible and cheap. These plans have been designed especially for the senior citizens of India, persons more than 60 years of age, to offer them maximum coverage including various treatments and other health care services. However, as with every insurance plan there are good things and thing that are not so good which really should not be the case, what is important though is to understand the details and avoid being caught up in the loop with the plan that they have laid out without our knowledge.
What Does a Senior Citizen Health Insurance Plan Cover?
1. **Hospitalization Expenses**
Hospitalization is one of the major parts of the health insurance of senior citizens in India. Some of the accommodation costs are room rents, nursing fees, ICU charges and other related charges during a patient stay in the hospital. Both pre-hospitalization medical expenses or treatment costs prior to admission into a hospital and post-hospitalization expenses or costs after the patient has been discharged are normally included in policies for a limited period.
2. **Day Care Procedures**
Most insurance plans include services relating to day care where treatment is not necessarily in hospital for at least one day. These are cataract surgery, dialysis, chemotherapy and other minor surgical procedures which are crucial to elderly patients.
3. **Critical Illness Coverage**
Some of senior citizen health insurance policies also contain provisions for critical illness like heart diseases, cancer, stroke, renal failure among others. Such illnesses affect the elderly most, and having an insurance cover have a way of easing the burden of having to cater for the illnesses.
4. **Pre-Existing Diseases**
Senior citizens’ products include pre-existing ailments but these are loaded after waiting periods of 1- 4 years depending on the insurance provider. Illnesses such as diabetes, hypertension and arthritis affect most of the ageing population and investment in these preserved diseases is crucial in the population’s heath.
5. **Domiciliary Hospitalization**
Domiciliary treatment means treatment taken at home if the insured cannot be transferred to a hospital due to his/her critical condition. A number of senior citizen health insurance policies do have provisions that also cover home nursing, so that the patients can also be treated if they are not in a position to be taken elsewhere.
6. **Ambulance Charges**
The policy may also include the cost of an ambulance especially where the need arises to evacuate the patient. This is important for the senior men and women since they may require being rushed to the health facility in cases of an emergency.
7. **AYUSH Treatment**
Some of the insurers pay for AYUSH based on Ayurveda, Yoga, Unani, Siddha and homeopathy treatments. There are elderly patients who wish to opt for traditional medicine, and hence policies that comprise of AYUSH treatments can benefit these people.
8. **Free Health Check-ups**
Other services that are needed for senior citizens include, check up because they also experience health complications. Many insurance policies prior to elderly people contain a provision for a annual medical examination. Thus policyholders are able to avail medical tests with a view of preventing or early diagnosis of diseases.
9. **Health Insurance for Organs Donation**
In case an insured senior citizen has to undergo the transplant surgery then there can be expenses required to treat the organ donor also included in the insurance. This entails use of donor’s money to cater for hospital bills when the donor was admitted for surgery.
10. **Home Nursing Care**
There are some conditions that are covered by the senior citizen health insurance policies; such as home nursing care if the insured needs it while recovering. This can be very crucial in the extended care of elderly people who may need surgery or intensive care.
Coverage Of Senior Citizen Health Insurance Plan Scheme And Exclusions Of Claim
Exclusions in Senior Citizen Health Insurance Plans
In as much as senior citizen health insurance has numerous benefits, there is always a list of things that are not covered as follows. These are generally different for each insurance provider but there are certain general exclusion categories that are commonly in most of the insurance plans.
1. ### **Whether Pre-Existing Conditions During Waiting Period are Considered** Some important points that need to get considered during pre-existing conditions of the waiting period are as follows:
While the policies state that pre-existing conditions will be excluded for a certain period and the provider will start offering coverage for the condition once the waiting period is over, it is important for the client to know that claims resulting from these conditions during the waiting period will not be honoured. Some of the plans may take as short as one year while others may take as long as four years.
2. **Some Selected Critical Illness in the First Waiting Period**
There are some conditions that the company does not cover within the first 30 days to 90 days after enrolment of the policy known as the waiting period for such a plan with regard to critical illnesses or particular treatments. There is a waiting period with regards to the sicknesses and this is unless for an accident since these has no waiting period.
3. **Cosmetic or Plastic Surgery**
Surgeries which are regarded to be aesthetic/ reconstructive/ voluntary orqusally are usually excluded. Operations such as facelifts, hair transplants or even obesity surgery are not allowed unless the person has undergone them due to an accident or an illness.
4. **Dental and Eye care treatments are as follows**
The basic dental and eye care procedures like dentures, spectacles and cataract surgeries are normally barred from cover unless they are as a result of an accident or disease. There are, however, a few which include a very restricted amount of dental and eye care as extras.
5. Hearing aids or external devices include any device used for the preservation of hearing that can be removed from the user or is permanently attached to the body but not for the treatment of diseases, disorders or defects of the ear.
Hearing aid, spectacles or contact lenses are considered as external medical appliances whereby in most insurance covers they are not reimbursable. These are regarded as general or optional health expenditures unless needed because of a health complaint which is an outcome of an accident.
6. **Self ingested Injuries and Substance Abuse**
Medical costs incurred as the result of self harm including suicide attempts; medical costs attributable to the use of alcohol, drugs or any other inebriating substances are not deemed qualified for reimbursement.
7. **Sexually Transmitted Illnesses (STIs) and Acquired Immune Deficiency Syndrome (AIDS)**
Most of senior citizen health insurance policies do not include STDs and HIV/AIDS treatment besides a few insurance companies are now offering limited treatment for HIV/AIDS patients.
8. **Other CAMs not in Scope of AYUSH**
Some policies may have AYUSH care including the coverage of treatments that may be outside of the government sponsored AYUSH program while the other policies may not cover all treatments that are outside the allopathic treatments. It is recommended to confirm from the particular insurer whether AYUSH treatments are reimbursable.
9. **Experimental or Unproven Treatments**
Generally, those procedures, which are still considered experimental or ineffective, as well as those treatments, which are considered nontraditional in comparison with the standard methods used in the medical practice, are not covered. For instance, certain treatment modalities that are yet to gain the approval of medical practitioners, or treatments which are still undergoing trials, may not be included.
10. **War-Related Injuries**
Accident or sickness caused as a result of war, terrorism or any military action are precluded from senior citizen health insurance products.
How to Choose the Right Senior Citizen Health Insurance Plan
1. **Evaluate Coverage Needs**
It is essential to first evaluate your healthcare requirements before direct buying a plan, thinking of those conditions that are normally pre-existing, the opportunity of the critical ailments, or more regularly check-ups. Choose a policy with few exclusions that would give adequate and sufficient coverage.
2. **Learn about the Pre Existing Diseases Waiting Period**
Due to this, most senior citizens may be already suffering from other diseases, and therefore, the plan selected for them should not take long before its coverage begins for such diseases. Choose a plan that compares best and select another one which offers the client coverage for pre-existing illnesses after a specific period.
3. **Sum Insured**
The sum insured should be enough to cater for potential amount that may be spent on hospitalization and other forms of treatment. If you are a senior citizen you are likely to spend a lot on medical bills so go for a policy that has a high sum insured or one which has no limit on the room rental.
4. **Co-Payment and Sub-Limits**
Most of the senior citizen health plans contain provision for co-payment; this is a provision that requires the policy holder to pay a certain portion of claim. There should be details on co-payment and sub-limit particularly on the room rental and the treatment cost to avoid high cost on self-funding.
5. **Network Hospitals**
Always take a look at the list of network hospitals that are offered by the insurer. It is always preferable to know the nearest good hospitals that operate under the cashless treatment so that one is not concerned about the cash part while dealing with health issues.
6. **Renewability and Premiums**
Make sure the plan is renewable for the lifetime because people who are applying for this policy will be in need of coverage when they will be older and in their seniority. Also, look at the premium charges that in most cases rise with the age of the policyholder and select a policy with cheap but quality service charges.
Conclusion
Health insurance for senior citizens can be said to be a social security system for the elderly since health care costs are known to rise tremendously. Knowing fully the coverage benefits of these plans and the exclusions will assist you make right decisions and select the right plan that fits your healthcare needs. In this case, it is recommended that one should take some time and look at the various terms, seek advice from insurance gurus and work with different insurance companies to identify the most suitable company to work with in regards to the new plan that one wants to subscribe too.