Day by day medical emergency costs are increasing. But the penetration of health insurance in India is abysmally low. To address this gap and to ensure health insurance for all, the Insurance Regulatory and Development Authority of India (IRDAI), the country’s insurance regulator, has introduced a standard health cover policy that must be offered by all general and standalone health insurers. This standard health policy is Arogya Sanjeevani. Insurance companies including HDFC Ergo, SBI General and Manipal Cigna have already launched this product and soon other insurers may follow.
Arogya Sanjeevani policy is a standard health policy as per IRDAI requirements, which means, the coverages and exclusions across insurers (offering this product) will be the same (including the policy name). Other clauses such as co-payment (cost-sharing requirement where a policyholder pays a certain percentage of the claim from his pocket) and sub-limits (a monetary cap on coverage for a particular treatment) will also remain the same.
This policy can be offered on individual basis as well as on family floater basis. The policy is for a year, which means, the policyholder has to renew the policy every year to ensure the benefit of the policy continues. Further, Arogya Sanjeevani is offered for a minimum sum insured (SI) of ₹1 lakh up to a maximum of ₹5 lakh. Like any other health policy, the standard policy too comes with minimum waiting period of 30 days and disease-specific waiting period (24 or 48 months depending on the diseases). The option of portability is also available for policyholders.
The Arogya Sanjeevani policy also offers cashless facility to its policyholders, provided hospitalisation is from network hospitals. Purchase of this policy can be made from across all distribution channels ― digital channels or through agents.
According to Prasun Sikdar, MD & CEO, ManipalCigna Health Insurance, “This standard policy was introduced to help people to buy health policy easily, without any confusion in policy terms. However, the insurers are free to adopt their own underwriting and pricing approach to bring in differentiation accordingly.”
Arogya Sanjeevani health policy covers hospitalisation expenses up to the sum insured, provided the policyholder is hospitalised for a minimum period of 24 hours consecutively. It also covers dental treatment and plastic surgery, provided it is necessitated due to disease or injury. Similarly, expenses incurred on road ambulance, subject to a maximum of ₹2,000 per hospitalisation, is offered.
Also, the standard health policy provides cover to all-day care treatments too. However, treatment of cataract is subject to a limit of 25 per cent of the sum insured or ₹40,000, whichever is lower, per each eye in one policy year.
There are certain procedures, taken either as in-patient or as part of day treatment, that are covered by Arogya Sanjeevani up to 50 per cent of the SI. Some of these procedures include oral chemotherapy, robotic surgeries, uterine artery embolisation, high intensity focused ultrasound and stem cell therapy.
Further, pre-hospitalisation expenses are covered by this standard health policy, provided it is for 30 days prior to hospitalisation. In the case of post-hospitalisation expenses, the policy provides coverage for 60 days from the date of discharge from hospital.
Argoya sanjeevani too comes with a set of exclusions. That is, the policy will not cover expenses such as maternity treatments, weight loss, unproven treatments, sterility and infertility, change of gender, hazardous adventure sports, of those caused by breach of law or due to war and refractive error. The policy also doesn’t provide coverage for out-patient department (OPD) expenses.
Also, there is a sub-limit on room rent. That is, if the policyholder is hospitalised, then room rent, boarding and nursing expenses would be limited to 2 per cent of the SI up to a maximum of ₹5,000 per day. Similarly, intensive care unit (ICU) expenses are limited up to 5 per cent of SI to a maximum of ₹10,000 per day. If you exceed the said limit of the policy, your claim gets reduced. This is because, the insurance company assumes a proportionate increase in other charges as well, and therefore, your claim will be settled only on proportionate basis.
Further, fixed co-pay of 5 per cent is applicable on the total eligible claim under this policy.
The policy also has a no-claim-bonus feature wherein your SI will increase 5 per cent for every claim-free year, subject to a maximum of 50 per cent of the sum insured.
Arogya Sanjeevani policy meets the objective of offering basic health policy with common covers. Since the coverage of policy is the same across insurers, you can select the insurer based on the premium.
“One of the functions that go into pricing is the underwriting process. So, those insurers aggressive on underwriting, that is, issuing policies without any medical check-ups, then the premium may be higher. But insurers with medical assessments, premium could be lower.”
For instance, for Arogya Sanjeevani offered by ManipalCigna for a 35-year old male for SI of ₹5 lakh, the premium works out to ₹6,299 (excluding GST). The premium in case of SBI General for the same policy works out ₹4,501 (excluding GST).
Arogya Sanjeevani anyway works out to be cheaper than other comprehensive health policy. For instance, HDFC Ergo Health Insurance (formerly Apollo Munich Health) for a 35-year old individual for SI of ₹5 lakh, the premium is around ₹6,755 (excluding GST). This policy provides a comprehensive coverage and offers other benefits such as multiplier benefits, coverage of 180 days of post-hospitalisation expenses, preventive health check-up, no sub-limit on ICU and e-opinion for critical illness.
Thus, while it is good to have Arogya Sanjeevani as a basic health cover, it would be better to have a health policy with higher SI, offering better benefits, as you age.
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