Will your health insurance cater for all your needs under the catastrophe cover?

Large number of people working in the private sector is subscribed to a medical insurance by their employer, whereby one or both parties contribute to the monthly premium. Some time back, there was even a proposal for the government to provide same benefit for those in the public sector because even they probably realized that you cannot always rely on public hospitals for numerous reasons.

Hence, the goal of having a medical insurance is to have a peace of mind when you need it, in the event you suddenly fall sick, get pregnant, the need to undergo some planned surgical procedure or just simply, for medical checkups to make sure that you are fit (and bug-free).

For anyone who needs more details, I previously talked on medical insurance covers on the following pages :

1. Waiving waiting periods (when you are changing jobs)
   https://yashvinblogs.com/2019/07/12/waiting-period-medical-insurance/
2. Claiming medical expenses
   https://yashvinblogs.com/2013/07/16/claims-health-insurance/

Additionally, you can read about life policies on this page : http://www.yashvinblogs.com/life-insurance/

Types of covers under a medical insurance scheme

When you need to subscribe for a health insurance, you will come across these 3 terms very frequently :

• In-patient cover
  Any medical treatment requiring admission in a private clinic
• Out-patient cover
  Any medical treatment which does not require admission and needs for optical / dental care
• Medical / Catastrophic / Surgical cover
  Coverage for advanced treatment / Extension of in-patient cover

As I mentioned besides each of the covers, they are applicable in different situations. Also, each one of them provide financial assistance up to their own limits, depending on the cover you / your employer is subscribing and depending on the offers made by the insurance company.

For example, you can have an in-patient cover of Rs 50, 000, an out-patient cover of Rs 10, 000 and a medical / catastrophic / surgical cover of Rs 1, 000, 000. Or you can choose to have only one or a combination of the covers.

What is a Medical / Catastrophic / Surgical Cover

This post will mainly focus on this cover and the name of the cover can differ from one insurance company to another. For the sake of simplicity, I will not talk about scale of costs. If needed, I will write another post on the topic.

The reason to subscribe to such cover is to extend the financial limit offered by the in-patient cover and unlike the in-patient limit which can cover anything from 50k up to 200k (depending on companies), the medical / catastrophic / surgical cover can have your back for up from Rs 500, 000 to Rs 10, 000, 000.

If you need to go for a surgical procedure costing Rs 300, 000 rupees, then, this cover will kick in after the limit of your in-patient is reached. If your in-patient was Rs50, 000, then in this scenario, this cover will provide the additional Rs 250, 000.

So, it makes sense for most people subscribing to a medical insurance plan to take such covers catering for any scenario requiring large amount of money.

Illnesses not covered under this cover

The list of illnesses / surgical procedures will vary from one insurance company to another, depending on their policy. They usually refer to this list as a exclusion list and they will not entertain any expenses related to an illness mentioned in that list.

For example, the medical insurance will not cover expenses if you are going for a plastic surgery to fix your curved nose or remove your double chin or remove your excess kilos of fat.

However, some medical insurance companies have other more specific illnesses in that list.

Pay attention to the wordings

Different insurance companies name this cover differently.

A quick look at a few offers on the Mauritian market :

• NIC Mauritius (ex-BAI) has a “Catastrophe Cover”, which is valid only for life-threatening situations, accidents and surgeries.
• Both SWAN and MUA have a “Medical and Surgical Catastrophe Cover” which is applicable for surgeries, accidents and medical conditions

Just to quote :

The Catastrophe cover excludes expenses related to dental, optical, hearing and maternity-related treatments and, medical conditions treated conservatively (e.g. pain management, bronchitis, gastroenteritis, etc.).

Source : NIC terms and conditions: Pg 7 paragaraph 11. Catastrophe Cover

Inquire about your current medical cover

For those who follow the blog, the huge catastrophe cover subscribed for each of my family member was totally useless when Dhaneesha got seriously ill in April 2021 after her Covaxine shot. The insurance company categorized her illness as pain management, hence, they covered the expenses for in patient cover only, amounting to an amount of Rs60, 000 on each of the two admissions to Wellkin Hospital. This left us with an unpaid bill of Rs300k!

In a moment of pain, this was totally unexpected, especially since no one really pays attention to all the small prints, despite being mentioned in the terms and conditions. Furthermore, no one has been in a similar situation whereby pain management was excluded and their bill was not covered by the catastrophe cover.

Anyway, it is no use crying over spilled milk. The most important part is that Dhaneesha is now back on her feet. Immediately following this event, I personally invested more time doing some home work and consequently, the whole company moved to a new insurance company….

To everyone out there, grab a copy of the terms and conditions of your medical insurance or ask your human resource department to inquire which illnesses are not covered by the Catastrophe cover and whether all medical conditions are included.

You will thank me some day for saving your arse, and your hard earned money….