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Introduction
 
Ques. Who is a Third Party Administrator ?
Ans. TPA is an abbreviation for Third Party Administrator. These companies are BPO of insurance companies and are responsible for coordinating all aspects of claims arising due to health insurance policies.
These companies are licensed by IRDA (Insurance Regulatory & Development Authority) and are having
  • Telecom facility generally with phone number starting with 1600 (toll free no.)
  • Computer network having details of all policies holders.
  • Medical specialists, for assessing need for hospitalization treatment being given in the hospital and for passing of the claim bills.
The role of TPA is to coordinate with hospitals with respect to treatment and also pass the bills on behalf of the insurance companies. The actual payment is made by the insurance company. As far as the legal contract is concerned, it is between the insurance company and the person insured.
The individual insured will get an ID card issued by the TPA. This ID Card is useful and needed at the time of hospitalization.
Ques. Are naturopathy and homeopathy treatments covered under a health policy ?
Ans. In all policies naturopathy is not covered. However Homeopathy is now being covered by some insurance companies provided treatment is taken in a Homeopathic Hospital, which is empanelled with the insurance company. Star Health permits use of Homeopathic medicines during post hospitalization period.

We foresee more and more insurance companies will start covering naturopathy and homeopathy treatments in future as more and more organized hospitals covering naturopathy and homeopathy will come up.
Ques. Why should I buy a critical illness cover?
Ans. Critical Illness cover is for specific diseases like cardiac/cancer etc. Generally list comprises of 8 to 12 but in a specific company this may be as high as 35.On happening of the diseases lump sum payment may be made – giving you the option of choosing the treatment. For example you may like to have naturopathy or yoga path as guided by Baba Ram Dev. Generally this policy is given by Life Insurance Companies as a stand alone policy or as an additional rider in your life insurance policy (against some additional premium).Even now you can add it to your existing policy in case it does not have this rider.
Ques. Does my Individual Insurance Policy cover mental health benefits (treatment for mental diseases)?
Ans. No it does not cover treatment for mental diseases. We do hope that in near future insurance companies will come out with innovative products which will cover this.
Ques. Will my health insurance coverage Clinical Trials?
Ans. We feel that if treatment is
  1. Part of hospitalization in a reputed hospital like AIIMS, capable of conducting clinical trials under controlled conditions.
  2. Under supervision of a reputed doctor
  3. Clinical trials are approved by  Medical Council (Ministry of Health)
Then it will be payable. If it does not fulfill these conditions then you may have difficulty in getting it paid as the issue is around treatment as well as the price of the medicine.
Ques. What's the Difference Between Co-pays and Co-insurance?
Ans. Copayment is that what % you will pay and the balance is to be paid by the insurance company.
Coinsurance is not applicable to individual’s health insurance policy. It is applicable to insurance of large plan with premium say Rs 20 lakhs and above where 2 or more insurance companies share the premium and the risk. The insurance policy is issued by Insurance Company having maximum share, then it collects the premium and gives cheque to other insurance companies. At the time of claim, they pay the claim and collect the amount from the insurance companies.
Ques. Which medical tests does an adult above 45 years needs to go through?
Ans. It depends on the company. Generally it comprises of
  • Blood Tests
  • Urine Tests
  • ECG
As the age progresses, the list increases. For 60/70 years, the list will comprise of extra tests.
Ques. I have been covered by my husband's group health plan through his job, but now we are getting divorced. What will happen to my health benefits?
Ans. You will lose the benefit. You should buy Health Insurance immediately out of your funds.
Ques. I own a pet and my vet bills are sky-high. Is there such a thing as health insurance for animals?
Ans. It depends on pet. But definitely it is not part of Health Insurance policy which is for human beings only. Cow, buffalo are covered under Cattle Insurance. Please describe the pet so that we can answer your question more specifically.
Ques. Is the Critical Illness policy just another name for the Mediclaim policy ?
Ans. No both are very different products.
Ques. Who is entitled to an overseas mediclaim policy?
Ans. It can be purchased by any one who is planning to undertake overseas trip (foreign trip) by road/sea/air. Your normal policy is valid only in India and is not valid outside India.
Ques. Should I pay my premiums through the agent?
Ans. If he is ready to provide you the service – yes. It is your duty that cheques should reach the insurance company well in time. Not picking up of the cheques by the agent is no excuse. If your cheque has not reached the insurance company on time, your policy may have a break and you may lose the benefits.
Ques. Is there any disadvantage if we buy health insurance as part of group insurance (for e.g linked to account holders of banks) if the right cover amount is taken.
Ans. There is no disadvantage. You should keep in mind that if you close your account with that bank then you are out of that group and hence the benefit of policy is also gone.
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ASSOCHAM - 10th Global Insurance Summit on 22nd September 2017 at Hotel Taj Lands End, Mumbai   more........
 
Upcoming Seminar
ASSOCHAM - 10th Global Insurance Summit on 22nd September 2017 at Hotel Taj Lands End, Mumbai
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