Mrs. Rajani recently went for her annual check-up with her general physician who noticed that Mrs. Rajani had elevated blood pressure levels and she also complained of bouts of fatigue and sweating after moderate activity. Her G.P. advised her to take blood pressure medicines for some days and told her to do some tests to rule out any heart ailment. Mrs. Rajani thus underwent lipid profile, ECG, stress test even 3D echo, as her doctor recommended. The results of the tests came out and fortunately for Mrs. Rajani, the results showed nothing out of the ordinary. Mrs. Rajani, though happy, wasn’t pleased that she had to pay six thousand rupees for nothing. She promptly called her agent and asked if she can claim the amount from the health insurance company.
Her agent replied in the negative. Mrs. Rajani was outraged, she had paid her premium for so many years, shouldn’t the health insurance company reimburse for the health costs - in this case, the diagnostic tests. If you are also wondering why diagnostic tests are not covered, here are some reasons
Health Insurance in India= Hospitalization Insurance
Unlike in some of the other countries in which health insurance provides cover for all health related expenses, Health insurance coverage in India is restricted to hospitalization, which means that health insurance companies will only pay claims hospitalization expenses.Thus all OPD expenses like consultation fees, expenses on medicines, dental expenses are not payable by default. So even if some of the tests, for example- MRI scans, are very expensive, these costs are not payable in most of the health insurance policies.
But Diagnostic Tests are paid for, if
- You are hospitalized due to findings of the test you took. For example if Mrs. Rajani was detected with clots in her arteries and needed to undergo any treatment like Angioplasty, cost of her diagnostic tests would be paid under the health insurance policy. She could then claim the amount she spent by sending the receipts and report of the test as a part of Pre-hospitalization expenses where all medical expenses relating to the treatment incurred upto 30 days before the hospitalization are payable. This 30 day period of course varies from policy to policy, but in most policies this period is 30 days.
- If you require these diagnostic tests as part of the treatment for which you are hospitalized. That is if your doctor advised some blood tests, x rays during your stay in the hospital, these are also paid for.
Note: There may be sub limits on these. For example – in the health insurance policy of National Insurance, “ Anesthesia, Blood, Oxygen, OT charges, surgical appliances, Medicines, drugs, Diagnostic Materials & X-Ray, Dialysis, Chemotherapy, Radiotherapy, cost of pacemaker, artificial limbs and cost of stent and implant. Maximum limit per illness – 50% of Sum Insured.”
Also note that the tests are payable only if they are a part of your treatment.
Health insurance that cover OPD expenses
Though regular health insurance policies do not cover OPD expenses there are certain policies like ICICI Lombard’s Health Advantage, Star Health’s Health Gain and Apollo Munich’s Maxima Health insurance plan that cover your OPD expenses including expenses on dental treatment, consultation and diagnostic tests upto a limit. You have to keep all the bills with you and claim reimbursement of the amount once in a year. Though this benefit is a good one, the premium slabs are naturally greater compared to other policies for the same sum assured. There is no thumb rule to decide whether it makes commercial sense for you to pay this higher premium. The deciding factor would probably be your disposition to be afflicted by minor ailments that would warrant expenses of the above nature.
Three Claim free years later
Almost all health insurance companies give a free health check up to the customers who have completed cover for three or four claim free years without break with the company. The amount upto which your health insurance bears the cost of such tests is a specified percentage of your Sum Insured. You need to get these tests conducted in the authorized diagnostic centers.
For Policies from Private Health Insurance Companies:
You will get a Health Checkup coupon at the time of the renewal of health insurance policy on completion of your three of four claim free years. You need to take this coupon to an authorized diagnostic centre (list, mentioned on the coupon) to undergo the check up.
For Policies from Public Health Insurance Companies
You need to get the ‘No Claim Confirmation’ from the TPA after completion of the required claim free years. You can get a checkup done after which you send your original bills and copies of reports to the TPA for reimbursement of cost upto 1% of the sum assured.
Note: Even though most diagnostic tests are not covered unless they lead to hospitalization, Angiography is covered by most health insurance policies irrespective of positive or negative confirmation of disease.
We hope that all your doubts regarding diagnostic tests are cleared in this article .
