Unfortunately in India, we do not have a system of giving accreditation to various health plans. So, customers learn it...…the hard way. It is very sad but a harsh reality that when it comes to health insurance, insurers sell what they want to rather than what you need.

Often, the Manager responsible for purchasing Group Health insurance in a corporate drives up a good bargain, writes the premium cheque and feels happy that he has had a good deal. Such corporate clients often comprehend the insurance coverage only after a disaster strikes, when a life threatening situation arises for an employee or a family member and the TPA throws up a surprise by stating that the coverage is not adequate or there are sub-limits in the coverage and hence the claim is partly settled.

The fine print of an insurance policy is almost never explained by an insurance company while selling the plan. The entire focus is on presenting how great a company they are, who are their clients etc. which do not really make a serious difference to the buyer. Health insurance is a tailor-made product and while you get excited about the big insurance coverage and the low price, the Underwriter could quietly insert caps, exclusions and clauses which will hit after your policy comes into force.

It is extremely important  to make sure you understand the ins and outs of the health plan you're buying. Often when plans are presented, the presenter will show you a summary of benefits. Behind that summary there are details of coverage, the fine print. Corporates often won't receive those details until after purchasing the plan, unless they demand it up-front.

For example, two plans may offer a family floater of Rs.5 Lakhs. But one plan may put a cap of Rs.2 Lakhs for parent claims while the other may  not have the cap. The difference is when a parent claim for Rs.3.50 Lakhs is made in the former plan, the employee will end up paying Rs.1.50 Lakhs from his pocket. Similarly, while offering a corporate buffer, one plan may deny it for parents while another may not.

Here is a list questions you should ask of a health plan before you make your decision:

Choice of TPA : Does your insurer offer you a choice of TPA ? Have you done your home work to figure out which TPA would suit your requirement ?  If you have offices in multiple locations or if your employees have dependents across India, it would be prudent to go with a TPA with a pan-India presence. Srinivas Raju, President & Lead Consultant for Health Insurance at Dr. Insurance says, “Over the past couple of years, the chaff got separated from the wheat in the TPA market and there are a handful of TPAs who have emerged as dependable. There have been instances when reputed hospitals have black-listed certain TPAs and refused to honour cards issued by them. It is very important for Corporates to do a reality check before deciding on the service provider”.  It would be too late for you if your employee ends up at the reception desk of a hospital and finds out the cash-less card he is carrying is not accepted.

Guest Consultants : Are you stuck with a consultant who thinks the job is over when the health program is placed. Are they involved in the daily governance of the program ? Are they part of the escalation process ? Are they actively involved in the implementation of the program ? If the answer is NO, junk them right away. The brand name and reputation of the consultant / broker should not matter to you. 

The fine print: Be aware of the circumstances under which a plan will and will not cover some conditions or put a cap on the expenses. If you have a coverage of Rs.2 Lakhs but your plan has a cap of 1% Room rent, chances are your pocket will be hit when you go to a muti-speciality hospital. Not just the room rent, you will end up paying the differential for other costs of the treatment also. More and more insurance companies are resorting to this technique to cut their claim cost. Needless to say, nobody tells you the implications of these caps before you buy the plan.

Out-of-pocket expenses: Know the plan's co-payments, caps and maximum annual payouts. Find out what are the expenses that you would need to pay when you are signing out from a network hospital.

Inclusions & Exclusions : Did you notice that including a new employee mid-way through the policy is more expensive than insuring them from policy inception. Chances are, you are being taken for a ride. Ask for the rates in advance, check if you are charged on pro-rata basis for inclusions and refunded for deletions when employees leave.