Mpox, dengue, Covid, & more: Does your health insurance cover outbreaks?

As outbreaks like Mpox increase, so do medical costs. But the question is: does your health insurance cover such diseases?

Mpox, Ebola, Covid-19, dengue — these outbreaks are now household names across the world. The frequency and intensity of such diseases are becoming more common. Jeremy Farrar, Director of Wellcome, a global health charitable foundation, says, "We are going through an era of epidemics and pandemics, and they are going to be more complex and more frequent."

As these outbreaks increase, so do medical costs. But the question is: does your health insurance cover such diseases?

The emergence of diseases like Mpox, which the WHO has declared a Public Health Emergency of International Concern, raises concerns similar to those seen during the Covid-19 pandemic.

"The good thing is that most standard indemnity-based health insurance policies in India will cover hospitalisation expenses incurred for treating diseases like Mpox. Indemnity policies are designed to cover a wide range of illnesses, including new and emerging infectious diseases that require hospitalisation," explains Bhaskar Nerurkar, Head of the Health Administration Team at Bajaj Allianz General Insurance.

Siddharth Singhal, Head of Health Insurance at Policybazaar.com, adds, "While there might not be exclusive plans only for emerging infectious diseases, they are all generally covered under the broader umbrella of hospitalisation under health insurance."

Nerurkar also mentions, "Some insurers may offer additional riders that enhance coverage during pandemics or epidemics, but these are not disease-specific."

So, if you have a comprehensive health insurance plan, any hospitalisations due to the Mpox virus will likely be covered by your insurer. However, as Nerurkar advises, "It’s wise to review your policy details and consult with your insurer to ensure you have comprehensive coverage for any emerging infectious disease."

Costs covered by insurers for outbreaks

"Health insurance plans offer a range of benefits, including coverage for hospitalisation expenses, daycare procedures, ambulance charges, consumables, and room rent," says Mahesh Yelapure, Head of Health Underwriting & Health Claims at Go Digit General Insurance. The specifics of coverage, however, depend on the chosen plan and its terms.

But, yes, there are some out-of-pocket costs that policyholders should be aware of.

While most hospitalisation expenses are covered, you might still face out-of-pocket costs for things like OPD treatment or certain policy coverages. "For example, if your plan includes a co-payment clause, you may need to pay a specified portion of the medical bill. Additionally, while cashless claims at network hospitals eliminate upfront payments, non-network hospitals may require you to pay upfront and later claim reimbursement," Yelapure points out.

"Additionally, all standard health insurance policies have a 30-day waiting period, so any claim made during this time won't be covered," says Parthanil Ghosh, Director and Chief Business Officer at HDFC ERGO General Insurance Company.

Common out-of-pocket costs

According to Singhal, some common out-of-pocket costs include:

Consumables: Health insurance typically doesn't cover the cost of medical items and supplies used during hospitalisation or treatment.

Co-payment: Some plans may have a co-payment clause, meaning the policyholder has to pay a certain percentage of the claim amount.

Deductibles: A deductible is the amount the policyholder must pay before the insurance company starts covering the costs.

How to ensure you are covered during an outbreak?

Nerurkar suggests the following steps to ensure adequate coverage during an outbreak:

1. Keep your policy active: Ensure you have an active health insurance policy that covers hospitalisation since most policies will include coverage for infectious diseases requiring hospital treatment.

   

2. Review your coverage: Regularly review and update the sum insured based on your needs. Considering the rising costs of healthcare due to medical inflation, it’s essential to choose a sufficient sum insured.

3. Consider additional riders: Adding riders that cover consumable items, often excluded from standard policies, can help minimize out-of-pocket expenses for items like gloves, masks, and other necessary supplies.

4. Select a comprehensive plan: Choose a health insurance plan that includes coverage for modern treatments, as these may be essential if advanced medical procedures are needed during an outbreak.

"Look for policies with lifelong renewability, especially if you're thinking about long-term coverage. Also, check the age limits for entry and renewal, as some policies have restrictions," Parthanil Ghosh adds.

Policy Bazaar lists out some options for a 30-year-old individual looking for a base cover of Rs 1 crore in Delhi:

1. Care Health - Care Advantage: Rs 15,479 (Premium including GST)

2. Star Health - Smart Health Pro: Rs 15,515 (Premium including GST)

3. Manipal Cigna - Lifetime Health: Rs 13,297 (Premium including GST)

4. Aditya Birla Health Insurance - Activ Fit Plus: Rs 17,058 (Premium including GST)

5. Niva Bupa Health Insurance - Reassure 2.0 Platinum: Rs 24,605 (Premium including GST)

6. HDFC Ergo - Optima Secure: Rs 25,781 (Premium including GST)

7. Bajaj Allianz General Insurance - My Health Care Plan: Rs 22,438 (Premium including GST)

Documentation required for claims

To ensure a smooth claim process, you need to have the following documents ready:

1. Original claim form, duly completed and signed.

2. Valid identity proof (e.g., Aadhar card, PAN card, Voter ID).

3. Doctor’s prescription recommending hospitalisation.

4. Doctor’s prescription advising diagnostic tests, medicines, and consultations.

5. Original pharmacy bills for medications and treatments.

6. Policy details, including the policy number, name of the insured, and the disease being treated.

For cashless treatments at a network hospital, you’ll need to provide a claim pre-authorization form and valid ID proof with a photograph. The hospital will handle the submission of required documents to your insurer.

In contrast, for reimbursement claims, you’ll need to collect and submit all relevant documents, including medical bills, from the hospital where you were treated. After the insurance company verifies the submitted documents, the claim amount will be transferred to your bank account.

What should you consider when choosing a health insurance plan?

Singhal suggests the following points when choosing a health insurance plan that covers emerging diseases:

1. High-sum insured: Such diseases can lead to expensive medical treatments, so ensure you have a plan with a high sum insured. For metro cities, a minimum cover of Rs 1 crore is recommended.

2. Buy early: Purchase the insurance as soon as possible, as there is usually a waiting period associated with most conditions.

3. Add-ons: Consider buying add-ons like consumables to reduce out-of-pocket expenses.

4. No room rent capping: Opt for a plan with no room rent capping to ensure comfort during treatment.

5. OPD cover: Consider buying OPD cover as some conditions may not require hospitalisation but will still incur costs for doctor consultations, medicines, and diagnostics.

Nerurkar advises that specific preventive measures can impact your coverage, including:

Travel restrictions: Travelling to areas with government-issued travel restrictions due to health risks might affect your coverage.

Regular health screenings: Insurers encourage regular health check-ups, which can lead to lower premiums or discounts.

Vaccinations: Keeping up with recommended vaccinations can influence coverage, especially for diseases like influenza or hepatitis.

Lifestyle choices: Healthy lifestyle practices, like regular exercise and a balanced diet, can positively impact your coverage, often resulting in lower premiums or additional benefits.

How are insurers adapting to the rising number of outbreaks?

"Many insurers are now using telemedicine, an important aspect of Medtech, to ensure healthcare remains accessible, especially during quarantine or when visiting a doctor in person isn't possible. At HDFC ERGO, for example, we introduced a free Teleclinic service during the Covid-19 pandemic to help people consult with doctors and get medical aid easily. This service was made available not just to our existing customers but also to non-customers, showing our commitment to supporting the wider community during tough times," Ghosh explains.
 

Recently, the Insurance Regulatory and Development Authority of India (Irdai) mandated that all cashless claims be processed within three hours of receiving a discharge authorisation request from the hospital. Insurers are also gradually adopting the National Health Claims Exchange (NHCX) platform, promising faster and simpler claim settlements.