You can get health insurance despite lifestyle diseases but at higher premium
India is home to the largest number of diabetics and heart patients in the world. Consequently, a large section of the population does not have easy access to health cover. While group schemes insure such diseases, getting cover is a grey area for individuals. The Insurance Regulatory and Development Authority of India (Irdai) has proposed permitting permanent exclusions for some diseases so that individuals can obtain health insurance for unrelated illnesses.
“Many who have undergone coronary stenting are denied cover despite long survival periods. Even those who undergo angiography or preventive treatment are labelled heart patients and deprived of cover or premium loaded,” says S. Prakash, JMD, Star Health and Allied Insurance, which offers covers for such conditions.
Even if insurers agree to take them on board, the premiums are steep. “Even select policies that do cover such conditions have a loading ranging from 30-300%,” says Abhishek Shah, CEO, Wellthy Therapeutics.
If you are suffering from a lifestyle disease, first enquire rather than assume you cannot obtain health insurance. Even under regular policies, you could be covered provided your parameters are within admissible limits. “Depending on the insurer’s underwriting policies, diabetics can be covered if blood sugar levels are acceptable,” says Sanjay Datta, Chief, Underwriting, Claims and Reinsurance, ICICI Lombard.
For instance, if the HbA1c score is under 6-7, you can get a health cover without premium loading or restrictions. “There is no uniformity in acceptance of these conditions. Most insurers accept hypertension with a loading as long as it is under control. The position on diabetes is a little more mixed. Many insurers reject while some accept with loading if it is under control,” explains Rudraraju Rajagopal, Senior VP and Head of Health Product and Claims, Tata AIG General Insurance.
Enquire with several insurers to land a better deal. Do not be disheartened by proposal rejection or premium loading. “Loading depends on health status, family medical history, underwriting guidelines, sum insured, plan type and related parameters,” says Prasun Sikdar, MD and CEO, ManipalCigna Health Insurance.
Premiums will be steeper if say your diabetes control is lax, besides other factors.
“The loading depends on the benefits the customer is going to get. For example, if the coverage for the condition is from Day 1, then premiums are higher. Stage of the condition also matters. Type II diabetes with high HbA1C and/or on insulin will carry a higher premium loading,” says Shah. If you have more than one lifestyle condition, again your premium would be higher.
Despite paying higher premiums, you may have to pay from your pocket in the initial years in case of waiting periods. “Pre-existing conditions can raise your premiums even if the insurance does not cover these ailments. This is because the policyholder is more likely to have additional issues related to the conditions,” says Ratheesh Nair, Founder and CEO, Watch Your Health. This should not lead you to conceal ailments at policy inception. It can haunt at the time of claim settlement.
Given the extent of lifestyle diseases among the population, some insurers offer dedicated covers for cardiac conditions and diabetes. While Star Health offers Diabetes Safe and Cardiac Care, Apollo Munich’s offering for diabetics is ‘Energy’. Premium variants of Manipal Cigna and Aditya Birla Health Insurance provide wellness services and programmes for managing lifestyle ailments and reward points that can be set off against renewal premiums, reducing the outgo.
Most such plans also have an element of covering OPD expenses. Religare Health’s Care Heart, for example, offers an optional cover that pays for doctor’s consultation, pharmacy bills and diagnostics. Aditya Birla and Manipal Cigna cover the same under their health management programmes. “Under such plans, premiums are decided on annual check-ups. A target-based approach is taken wherein the customer improves his health which shows up during the yearly checkup and other health metrics. Rewards are given and discounts on premium unlocked,” says Shah.
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Policyholders need to be aware of sub-limits, co-pay and other restrictions.
*For a 45-year-old woman. *With wellness and no co-pay
Such dedicated plans come with ailment-focussed benefits. For example, Star Health’s policy for diabetics promises to pay dialysis expenses of Rs 1,000 per sitting for 24 months, provided the policy is in force. It also covers the cost of artificial limbs due to amputation, up to 10% of sum insured.
Since active management of lifestyle diseases can result in improved parameters, such plans look at rewarding policyholders for healthy choices leading to favourable outcomes. For example, Apollo Munich’s Energy offers renewal discounts and wellness incentives if policyholders manage their hbA1c scores, BP, cholesterol levels and body mass index in accordance with a pre-designed chart. Total points translate into discounts of up to 25% on renewal premiums.
Keep an eye on restrictions
On the flipside, you need to be aware of sub-limits, co-pay and other restrictions. Under Star Health’s Diabetes Safe’s Plan B, the coverage for cardiovascular diseases related to diabetes comes with sub-limits. Also, there is a waiting period of a year for diseases linked to cardiovascular system, renal system, eyes, diabetic peripheral vascular diseases and foot ulcer under this variant.
Religare’s plan comes with a 20% co-pay ratio, which goes up by 10% per claim in the policy year once the insured crosses the age of 71. While there is no waiting period in Apollo Munich’s Energy for ailments related to diabetes and hypertension, other pre-existing diseases have two-year waiting periods. Besides, overall premiums are bound to be higher given the focus on health management. While these products are not optimal as regular health plans, consider these if you have exhausted all attempts to buy a base health policy or if premiums or restrictions on account your pre-existing conditions are stifling.