How to Read a Summary of Benefits and Coverage under Health Insurance?

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How to Read a Summary of Benefits and Coverage under Health Insurance?

As much as it pains to dig into your health insurance policy terms— understanding them is equally important. While you may skip a few pages, a grasp of the major policy conditions, exclusions, and terms is essential to avoid last-minute hassle during claim settlement. This article highlights the key documents you must check while receiving soft copies of your health policy.

At Care Health Insurance, we ensure that you know every policy-related clause, from general policy information to plan types and costings. It helps us serve you the right health insurance policy.

Contents of a Health Insurance Policy Document

The soft copy of the health insurance summary collects essential information concerning the selected policy and the insured members. Below are some major summary items to check as a policyholder:

1) Policy Certificate 2) Key Policy Information
It is the first document of the policy summary, consisting of the insured member’s details. Here, you will find the details of the selected policy, the policyholder’s details, and the sum insured opted for. The key information to check here is the policy start date, the insured person’s age, and pre-existing diseases, if any. This section combines the schedule of benefits under your policy, special conditions, and any optional benefits and add-on covers opted for along with the policy. Also, you must note the three types of waiting periods applicable to the selected plan, and in case of disagreement– you can raise a query within 15 days of issuance.
3) Premium Acknowledgement 4) Proposal Form
Under this section, you will find the complete break-up of the premium you have paid against the health policy. Here, you can verify the additional charges of the add-on benefits and the total tax paid. Also, this section will inform you about the eligibility criteria for availing tax benefits under section 80D of ITA. A proposer is a person who initiates a policy purchase on behalf of the insured person. This section contains personal information about the proposer. Also, you can verify additional details like the insured’s status of pre-existing diseases, claim filing history, and coverage under any other type of health insurance.
5) Policy Terms and Conditions 6) Health Card
The last section of the policy summary elaborates on all the policy terms and conditions. You should refer to this section basis the clauses mentioned in the policy’s schedule of benefits. For instance, you should refer to the exclusions and terms clause under the clause related to additional benefits. This section contains the soft copy of the insurance health card. The policyholder needs to produce this card and other documents to avail of a cashless facility at a network hospital. The card holds the insured member’s ID number, name, DOB, and the insurance company’s customer service contact details.

Steps to Read and Understand the Summary of Benefits in Your Health Insurance Policy

Once you have acknowledged the receipt of the above-mentioned policy documents, the next phase is to comb through the details. Here are the steps to better understand your health insurance policy summary:

Step 1: Verify the Insured’s Details on the Policy Certificate

The first step is to check the name, date of birth, and mailing address of the insured member as mentioned on the policy certificate. Also, as mentioned on the proposal form — you must cross-check the answers to the questions about pre-existing diseases and other health insurance (if available). Here’s an example-

policy coverage

Step 2: Check the Policy Coverage and Optional Benefits

The next step is to head to the schedule of benefits, under which you should verify the coverage and benefits. It included the hospitalisation expenses, waiting period, sub-limits, and no-claim bonus as mentioned in the policy prospectus. Also, check for the optional benefits you have chosen while purchasing the policy. In case of any discrepancy or query, you can contact the insurer’s customer support. An example of the schedule of benefits is as below:

policy coverage

Step 3: Ensure that the Premium Amount is Correct

The third step is to evaluate the premium amount that you have paid against the policy. Check the break-up of the premium amount to understand how much you have paid for the additional benefits.

Step 4: Go Through the Claim Process, and List of Network Hospitals

The most important function of health insurance comes when filing a claim. Make sure you know the claim process, whether cashless or reimbursement. For a cashless facility, always mark a few top network hospitals near your residence to ensure a hassle-free claim settlement. You can find the list of network hospitals in your city by simply searching for the hospital names. Also, don't forget to download and save the health card you need for a cashless hospitalisation facility.

>> Also Read: 7-Step Guide to Fill Health Insurance Reimbursement Form

Step 5: Read the Policy Terms and List of Exclusions

The last step to fully understand your health insurance policy is to go through the terms and conditions. Although a dreadful task, you can simplify it by reading them based on the clauses attached to any benefit or coverage option.

For instance, your first stop should be the exclusion clause or section that elaborates on all the scenarios that are not covered under the policy. After reading the common exclusions, you can refer to the dedicated appendix for the list of diseases not covered under the policy.

Final Note

The policy documents demand your undivided attention to ensure you don’t miss out on or misinterpret any policy benefit. Thus, you should always take a look of all the conditions applied to save yourself from unnecessary stress and financial burden.

Disclaimer: Please verify the policy details and coverage with the official policy documents. Also, kindly consult a professional medical expert to verify the details of health concerns.

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