Medical Insurance - Maternity

[raptor3624]

Ok. Questions to fathers/mothers who have dealt with maternity insurance. Looking for inside info or warning info that could help me and cut short my hassles.

My company provides a family insurance of 2 lakhs with a 50k cap on Maternity. Medical insutance is provided by Bharti AXA handled by Family Health Plan Limited as TPA.

1. Should I go for Cashless transaction or Reimbursement? Some of my friends say sometimes cashless way doesn't cover all medical expenses due to some loopholes. While Reimbursement i.e pay all expenses myself and later claim it gets you mostly all the money. But Reimbursement has too much headache I feel.
2. Our case is different. There is a medical complication in the pregnancy due to which the baby is to be kept in a Neonatal(Newborn) ICU. Is the rent of the ICE etc all covered in the insurance?

I know the 2nd question can be answered by the TPA customer care themselves but I just wanna know for sure.

 

[mithun]

With a 50k cap on maternity, you will get 50k reimbursed / cashless if your expenses are more than 50k. Almost all expenses incurred at the Hospital (including prenatal care) are covered to that extent. I have had to use my medical insurance ( employer provided and same sum as yours) twice recently. Once in February 2014 for my treatment and again in February 2015 when we were blessed with a baby girl. Both the times I paid up front and later got the expenses reimbursed from the insurance provider because our hospital of choice did not have cashless tie-up with the insurance provider. Do chose the hospital without taking into consideration if it has cashless tie-up or not as getting reimbursement is also easier than I thought. I just needed to courier all original documents and a downloaded Form (duly filled) to the Insurance companies claim settlement office and got reimbursed within 30 days.
A C-Section delivery would normally cost you around 60k to 90k INR ( depends upon the facility chosen). In your case the additional expenses of pre-natal care are to be added and I have no clue how much that would cost. If you can bear the cost upfront without straining your finances, it is always better to pay up and get reimbursed later.
Good luck!

 

[raptor3624]

thanks mithun. That helps.
Specific questions.

1. I was told that all insurers cover 30 days prior to delivery and 60 days post delivery charges. But the insurance broker AON Global( who deals with FHPL and the insurer BHarti Axa) says "pre and post hospitalization is not payable for maternity as they are pre natal and post natal." This is given in the pdf sent to all employess when insuarance is renewed. So this holds?

2. Apollo Cradle has packages of 60k, 90k and 1.2k. has anyone dealt with such fee structure? how is the room rent divided form other expenses in such case.

3. Has anyone had any experience(unfortunately) with newborn ICUs ? Are all charges and rent for such equipment covered usually? My insurance contact says yes but he didn't give much detail.

4. Are all medicines/prescription drugs like anasthesia, child medicines covered?

5. What comes under CO payment?

 

[mithun]

Query 1 : As per terms of my Insurance provider I had to submit my claim within 30 days of discharge from Hospital, so post discharge expenses are seemingly not covered by my policy. Tests conducted prior to delivery might be covered. Feel free to call up the Insurance Company helpline ( not the broker's).

Query 2 : Yes, all medicines for the mother and child billed by the Hospital is covered. Anesthetics will most likely be part of OT charges and is also fully covered.

 

[axeman]

1. Go for cashless. Non-medical expenses need to be paid by you in any case, such as gloves, food supplied, tissues, disposable items etc. Only medical expenses are covered in the policy.

2. Complications during delivery : If this leads to extra charges above and beyond 50k for the "delivery", you will need to bear this in any case.

3. NICU/ Neonatal care/ Incubator expenses after birth of child: Covered separately in the policy, as the infant is treated as a new addition in the policy. These expenses are treated differently outside the 50k cap. Confirm with your TPA, my policy allowed this, as the company had explicitly negotiated for this and got it added in the policy wordings. Condition given: Inform the company HR to add the name of the Infant in to the policy ASAP after birth via email.

4. 30 days prior to delivery and 60 days post delivery charges are not applicable in case of pregnancy.

5. Packages differ as such: two people sharing a room, one person has a single simple room, one person has a single delux suite type room etc. Go for normal as you can afford, rest is all usually unnecessary. Remember, higher the class you choose, more the other expenses. i.e. every thing else becomes more expensive. Doctor per visit charge can increase from 600 to 1000/ 1500 rs as an example. Call the hospital, they will describe it accurately.

6. Co-payment: First the medical expenses that can be covered are segregated from non-medical expenses (you pay this 'a'). Then the medical expenses are capped to 50k (except NICU etc infant post delivery costs 'i'), rest you must pay on your own at discharge 'b'. Now, for the 50k + 'i', if your co-payment is 15%, you pay 15% of (50k + 'i') (call this 'c') rest goes to the insurance TPA for clearing.

7. You in effect have to pay 'a' + 'b' + 'c' at discharge, plus a 5k/ 10k deposit (refundable after 3 months). The deposit is to cover any refusal that the TPA may later have on the claimed items. Once the TPA clears the hospital bill (usually 2 months), you can approach the hospital and get the deposit back.

Hope this helps, drop me a PM with specific queries if any.

P.S. Use a credit card at time of discharge if you can manage your finances, will help reducing a lot of running around for cash.