Suffering from cardiac ailment? Apply for a customised insurance plan

These plans have limited sum insured, come with a waiting period, and require co-payment

September 29 is World Heart Day. According to a report by the American College of Cardiology, non-communicable diseases accounted for 65 per cent of total deaths in India in 2019. Of these more than 25 per cent could be attributed to cardiovascular diseases and related risk factors.

Reliance General Insurance recently conducted a study on coronary angiography (CAG) procedures performed in 19-35 and 36-45 age groups between 2018 and 2023. While the number of procedures increased by 160.9 per cent in the 19-35 age band between 2018-19 and 2022-23, it rose by 102.9 per cent in the 36-45 age band over the same period.

Given the severe financial implications, having a health insurance cover becomes critical. However, people who have survived a cardiac event find it difficult to obtain coverage. They should consider applying for a cardiac-specific indemnity plan.   

Cover for a higher-risk group

Cardiac patients whose proposals for a regular health insurance plan get turned down should apply for a cardiac-specific plan.

Says Siddharth Singhal, business head-health insurance, Policybazaar.com: “Their uniqueness is that they cover people who have already had a heart-related procedure.”

Their features are similar to those of a regular hospitalisation policy.

“They cover hospitalisation, pre-and post-hospitalisation, ambulance expense, Ayush treatment, and also offer a comprehensive health check-up,” says Manish Dodeja, head-underwriting and claims, Care Health Insurance.  

Adds Rahul M. Mishra, co-founder and director, PolicyEnsure: “Waiting periods usually apply before pre-existing heart conditions get covered.” The customer also gets covered for non-cardiac ailments.

These plans may also offer benefits like outpatient department (OPD) coverage, restoration, and no claim bonus.

 Limited coverage, higher premiums

These plans usually have a limited sum insured and may also have a co-payment requirement. They are also costlier than regular hospitalisation covers. Singhal informs that they could be 30-40 per cent more expensive.

 The timing of the cardiac event matters. Says Singhal: “They are generally sold to people who had a heart attack two to seven years earlier. If it is a very recent case, or if seven years have elapsed since the event, the customer may get this policy but cardiac ailments may be permanently excluded.”

Who should go for them?

People who have undergone a cardiac event should buy these plans. Says Nayan Goswami, head-sales & service, SANA Insurance Brokers: “People with an existing heart condition should immediately buy this product if they do not have a cover already or if they feel that their existing cover may not suffice to meet rising healthcare costs.”

 Dodeja adds that people with cardiac issues should also buy this plan if they only have group insurance coverage from their employers.

Check to run

According to Singhal, customers should first check whether their existing heart-related conditions will be covered or permanently excluded. Thereafter, he says, they should verify the waiting period— two or four years—for heart-related conditions. They should also check for room rent capping.

Goswami also suggests looking for clauses related to exclusion, sub-limit, and co-payment. “These may not be mentioned in the one-page brochure, so refer to the customer information sheet (CIS) or the policy wording,” he says.   

He suggests checking for a sub-limit on specific treatments. He elaborates that one product offers a sum insured of Rs 10 lakh but has a sub-limit of Rs 3 lakh for cerebrovascular, renal, cancer, and related ailments. The co-payment requirement, according to him, should preferably not exceed 10 per cent.

Goswami also suggests checking if the insurer has imposed a “personal waiting period" on you specifically. Mishra suggests assessing the strength of the insurer’s hospital network.

Buy cover early

Increasingly, people are suffering from cardiac ailments in their thirties and forties, instead of in their sixties. Says Singhal: “If you buy a health policy early while you are healthy, you will get a plethora of options.”

 Goswami suggests that cardiac patients should apply for a regular health insurance policy first. “An insurer might offer you coverage with a waiting period and some loading. If you do not get coverage because of the type or severity of your ailment, apply for a cardiac-specific plan.” 

Pros and cons of fixed-benefit plans

• Besides indemnity-based plans (which compensate you for hospitalisation bills), fixed-benefit plans covering cardiac ailments are also available
• These may be single-disease covers (for cardiac ailments only) or critical illness plans (where a number of dreaded diseases, including cardiac ailments are covered)
• If the customer is diagnosed with a disease covered under these plans, they pay a predecided fixed amount
• Such policies are a great add-on to the regular hospitalisation cover as they can be used to take care of many ancillary costs 
• Understand the specific definition and the stage of the critical illness covered
• Once they make a payout, these covers end