I am 68 years old and have an individual health insurance plan. I plan to undertake heart surgery. My insurer says it will pay a fixed amount, which is half the amount the hospital will charge. What should I do? Are there any options or strategies I should consider to make this situation more manageable?
Reply by: Ashish Yadav, Head of Products, ManipalCigna Health Insurance
Facing heart surgery with an individual health insurance plan can be challenging, especially when your insurer mentions they will cover only half of the hospital charges. To navigate this situation effectively, it’s essential to understand the specific terms and conditions of your policy and explore potential strategies to make it more manageable.
Insurance companies vary in their approach to procedures like heart surgery, and their policies may include co-pay provisions. Co-pay, in health insurance, means that you need to contribute a certain percentage of the medical expenses while the insurer covers the rest. The co-pay amount can vary based on the type of treatment or medication required.
In your case, with a fixed amount equal to half of the hospital charges, it seems like a 50% co-pay. This implies that for a heart surgery with a total cost of, say, Rs. 2,00,000, you would be responsible for paying Rs. 1,00,000, and your insurer would cover the remaining amount.
Co-pay is advantageous in some scenarios. It can help reduce an individual’s premium costs, making insurance more affordable, especially for individuals in excellent health. This is because insurance providers may consider that individuals in good health are less likely to require extensive medical care.
However, co-pay policies also have their disadvantages. If the co-pay amount is substantial, it might defeat the purpose of having insurance since you would need to bear a significant financial burden in case of a major medical event. Therefore, it's important to assess your current health status and financial situation to determine whether a co-pay policy is suitable for you.
Moreover, being 68 years old and having poor heart health makes it essential to carefully evaluate your insurance options. If your insurer applies mandatory age-based co-pay starting at age 64, you should discuss this with your insurer and explore whether there are alternative policies available without such limitations.
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Some strategies you can consider to make the situation of 50% co-pay for your heart surgery more manageable are:
Supplemental Insurance: Consider purchasing supplemental insurance or a critical illness policy that is designed to cover the costs associated with specific health conditions, including heart surgeries. These policies can fill the financial gap left by your primary health insurance.
Review Other Insurance Plans: Explore the possibility of switching to a different health insurance plan that offers more favourable terms for heart surgeries. Look for policies with lower or no co-pay requirements specifically for cardiac procedures. An insurance advisor can assist you in finding suitable alternatives.
(Views expressed by the investment expert are his/her own. E-mail us your investment queries at askmoneytoday@intoday.com. We will get your queries answered by our panel of experts.)
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