Ahmedabad-based Neeraj Patel, with a health insurance coverage of ₹10 lakh, found himself facing out-of-pocket expenses despite a cashless hospitalization. This scenario is not uncommon, as many policyholders discover certain expenses not covered under their health insurance policies only after receiving substantial bills.

Understanding General Health Insurance Coverage

While health insurance aims to cover all hospitalization-related expenses, this may not always be the case. Out-of-pocket medical expenses, incurred directly by individuals, often include costs not covered by insurance policies.

Certain expenses typically not covered by health insurance policies include:

OPD Expenses: Outpatient department costs such as doctor consultations, pharmacy bills, and diagnostic tests.

Consumables: Medical items and supplies used during hospitalization, including administrative charges, gowns, gloves, surgical blades, and syringes.

Admission for Investigation and Evaluation: Expenses related to admission primarily for diagnostic and evaluation purposes.

Hospitalization due to Pre-existing Diseases (PED) or Specific Illnesses: Costs incurred if hospitalization occurs before specified waiting periods are completed.

Additional Considerations

Even within covered expenses, policy limitations may require policyholders to pay additional costs out of pocket. Room rent caps, ambulance fees, co-payments, and deductibles are factors that can contribute to out-of-pocket expenses.

Add-ons to Mitigate Expenses

Health insurance policies often offer riders or add-ons to cover specific out-of-pocket expenses. Some key add-ons include:

Consumables Cover: This add-on provides coverage for consumable medical items and materials used during hospitalization.

OPD Cover: Extends coverage beyond hospital stays to include medical costs for doctor visits, tests, medications, and minor procedures.

Add-ons to Reduce Waiting Period: Options to reduce waiting periods for pre-existing diseases and specific illnesses, though they may come with higher premiums.

Selecting Comprehensive Coverage

Opting for insurance plans without sub-limits and deductibles allows policyholders to utilize the insured amount fully. It’s essential to choose a policy explicitly covering out-of-pocket expenses to avoid additional financial burdens.

However, striking a balance is crucial to avoid unaffordable premiums. Carefully consider add-ons that can significantly impact out-of-pocket expenses while ensuring they remain affordable over time.

In conclusion, understanding the limitations of general health insurance coverage and exploring add-ons tailored to mitigate out-of-pocket expenses are essential strategies for policyholders seeking comprehensive coverage and financial security.