Understanding the present situation and scenario, we have realised that ” A healthy breathe is the most precious thing an individual can have”.
It is that one single thing that makes us able to enjoy life in every aspect. life and the events which occur in our life are unpredictable and can happen anytime. We cannot control what can happen when, but what we can control is the reaction, how we deal with it, how we mitigate it, how we ensure the right response? How can we make it less damaging to our pockets and our emotional well being?
These are few simple questions, that come to our minds now and then. Keeping these scenarios in perspective We have a designed a comprehensive health guide, so you are all sorted for your health care needs.
The term ‘Health Insurance’ relates to a type of insurance that essentially covers your medical expenses. Like other policies, a health insurance policy is a contract between an insurer and an individual/group in which the insurer agrees to provide specified health insurance cover at a particular “premium” subject to terms and conditions specified in the policy.
What a Health Insurance policy would normally cover?
A Health Insurance in Pakistan would normally cover expenses quite well and necessarily incurred under the following heads regarding each insured person subject to the overall ceiling of the sum insured (for all claims during one policy period).
a) Room, Boarding expenses
b) Nursing expenses
c) Fees of surgeon, anaesthetist, physician, consultants, specialists
d) Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radiotherapy, Cost of the pacemaker, Artificial limbs, cost of organs and similar expenses.
• Sum Insured
The Sum Insured offered may be on an individual basis or a floater basis for the family as a whole.
• Cost of Health Check-up
Health policies may also contain a provision for reimbursement of the cost of health checkups. Read your policy carefully to understand what is allowed.
• Minimum period of stay in Hospital
To become eligible to make a claim under the policy, a minimum stay in the Hospital is necessary for a certain number of hours. Usually, this is 24 hours. This time limit may not apply for the treatment of accidental injuries and certain specified treatments. Read the policy provision to understand the details.
• Pre and post hospitalization expenses
Expenses incurred during a certain number of days before hospitalization and post hospitalization expenses for a specified period from the date of discharge may be considered as part of the claim provided the expenses relate to the disease/sickness. Go through the specific provision in this regard.
• Cashless Facility
Insurance companies have tie-up arrangements with a network of hospitals in the country. If the policyholder takes treatment in any of the network hospitals, there is no need for the insured person to pay hospital bills. The Insurance Company, through its Third Party Administrator (TPA), will arrange direct payment to the Hospital. Expenses beyond sub limits prescribed by the policy or items not covered under the policy have to be settled by the insured direct to the Hospital. The insured can take treatment in a non-listed hospital in which case he has to pay the bills first and then seek reimbursement from Insurance Co. There will be no cashless facility applicable here.
• Additional Benefits and other standalone policies Insurance companies offer various other benefits as “Add-ons” or riders.
There are also standalone policies that are designed to give benefits like “Hospital Cash”, “Critical Illness Benefits”, “women-centric policy” etc. These policies can either be taken separately or in addition to the overarching health policy.
A few companies have come out with products like additional policies to meet the actual expenses over and above the limit available in the basic health policy.
The following are generally excluded under health policies:
a) All pre-existing diseases (the pre-existing disease exclusion is uniformly defined by all non-life and health insurance companies).
b) Under the first-year policy, any claim during the first 30 days from the date of cover, for sickness/disease. This is not applicable for accidental injury claims.
c) During the first year of cover – cataract, Benign prostatic hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in the anus, piles, sinusitis and related disorders.
d) Circumcision unless for treatment of a disease
e) Cost of specs, contact lenses, hearing aids
f) Dental treatment/surgery unless requiring hospitalization
g) Convalescence, general debility, congenital external defects, V.D., intentional self-injury, use of intoxicating drugs/alcohol, AIDS, Expenses for Diagnosis, X-ray or lab tests not consistent with the disease requiring hospitalization.
h) Treatment relating to pregnancy or childbirth including cesarean section
i) Naturopathy treatment.
The actual exclusions may vary from policy to policy and provider to provider. In group policies, it may possible to waive/delete the exclusions on payment of extra premium.
• No short period policies
Health insurance policies are not issued for less than one year period.
FAQs on Health Insurance
Q. What is Health Insurance?
Ans. The term health insurance is a type of insurance that covers your medical expenses. A health insurance policy is a contract between an insurer and an individual /group in which the insurer agrees to provide specified health insurance cover at a particular “premium”.
Q. What are the types of Health Insurance available?
Ans. The commonest form of health insurance policies in Pakistan covers the expenses incurred on Hospitalization, though a variety of covers and policies are now available which offer a range of health covers, depending on the need and choice of the policyholder. The health insurance company usually provides either direct payment to the hospital (cashless facility) or reimburses the expenses associated with illnesses and injuries or disburses a fixed benefit on the occurrence of an illness. The type and amount of health care costs that will be covered by the health plan are specified in advance.
Q. Why is Health Insurance important?
Ans. All of us should buy health insurance and for all members of our family, according to our needs. Buying health insurance protects us from the sudden, unexpected costs of hospitalization (or other covered health events, like critical illnesses) which would otherwise make a major dent into household savings or even lead to indebtedness.
Each of us is exposed to various health hazards and a medical emergency can strike anyone of us without any prior warning. Healthcare is increasingly expensive, with technological advances, new procedures and more effective medicines that have also driven up the costs of healthcare. While these high treatment expenses may be beyond the reach of many, taking the security of health insurance is much more affordable.
Q. What kinds of Health Insurance plans are available?
Ans. Health insurance policies are available from a sum insured of Rs 5000 in micro-insurance policies to even a sum insured of Rs 50 lakhs or more in certain critical illness plans. Most insurers offer policies between 1 lakh to 5 lakh sum insured. As the room rents and other expenses payable by insurers are increasingly being linked to the sum insured opted for, it is advisable to take the required cover from an early age, particularly because it may not be easy to increase the sum insured after a claim occurs. Also, while most non-life insurance companies offer health insurance policies for a duration of one year, and need renewal annually some policies are issued for two, three, four and five years duration but these are Life insurance companies that have plans which could extend even longer in the duration.
A Hospitalization policy covers, fully or partly, the actual cost of the treatment for hospital admissions during the policy period. This is a wider form of coverage applicable for various hospitalization expenses, including expenses before and after hospitalization for some specified period. Such policies may be available on an individual sum insured basis, or on a family floater basis where the sum insured is shared across the family members.
Another type of product, the Hospital Daily Cash Benefit policy, provides a fixed daily sum insured for each day of hospitalization. There may also be coverage a policy available for a higher daily benefit in case of ICU admissions or specified diseases or injuries.
A Critical Illness benefit policy provides a fixed lumpsum amount to the insured in case of diagnosis of a specified illness or on undergoing a specified procedure. This amount helps mitigate various direct and indirect financial consequences of a critical illness. Usually, once this lump sum is paid, the health insurance plan ceases to remain in force.
There are also other types of products, which offer lumpsum payment on undergoing a specified surgery (Surgical Cash Benefit), and others catering to the needs of specified target audiences like senior citizens.
Q. What is a cashless facility?
Ans. Insurance companies have tie-up arrangements with several hospitals all over the country as part of their network. Under a health insurance policy offering a cashless facility, a policyholder can take treatment in any of the network hospitals without having to pay the hospital bills as the payment is made to the hospital directly by the Third Party Administrator, on behalf of the insurance company. However, expenses beyond the limits or sub-limits allowed by the insurance policy or expenses not covered under the policy have to be settled by you directly with the hospital.
A cashless facility, however, is not available if you take treatment in a hospital that is not in the network.
Q. What are the tax benefits I get if I opt for Health Insurance?
Ans. Health insurance comes with attractive tax benefits as an added incentive. There is an exclusive section of the Income Tax Act which provides tax benefits for health insurance, which provides a policyholder relaxation while filing his/her taxes. Health insurance ensures that at the time of need an individual can acquire the best services available in the market for the required medical care.
Q. What are the factors that affect Health Insurance premiums?
Ans. Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses. Previous medical history is another major factor that determines the premium. If no prior medical history exists, the premium will automatically be lower. Claim free years can also be a factor in determining the cost of the premium as it might benefit you with a certain percentage of the discount. This will automatically help you reduce your premium.
Q. What does a Health Insurance policy not cover?
Ans. You must read the prospectus/ policy and understand what is not covered under it. Generally, pre-existing diseases (read the policy to understand what a pre-existing disease is defined as) are excluded under a Health Insurance policy. Further, the policy would generally exclude certain diseases from the first year of coverage and also impose a waiting period. There would also be certain standard exclusions such as cost of spectacles, contact lenses and hearing aids not being covered, dental treatment/ s u r g e r y ( unless requiring hospitalization) not being covered, convalescence, general debility, congenital external defects, venereal disease, intentional self-injury, use of intoxicating drugs/alcohol, AIDS, expenses for diagnosis, x-ray or laboratory tests not consistent with the disease requiring hospitalization, treatment relating to pregnancy or childbirth including cesarean section, Naturopathy treatment.
Q. Is there any Waiting Period for claims under a policy?
Ans. Yes. When you get a new policy, generally, there will be a 30 day waiting period starting from the policy inception date, during which period any hospitalization charges will not be payable by the insurance companies. However, this does not apply to any emergency hospitalization occurring due to an accident. This waiting period will not be applicable for subsequent policies under renewal.
Q. What is a pre-existing condition in a health insurance policy?
Ans. It is a medical condition/disease that existed before you attained a health insurance policy, and it is significant because the insurance companies do not cover such pre-existing conditions, within 48 months before the 1st policy. It means pre-existing conditions can be considered for payment after completion of 48 months of continuous insurance cover, the coverage of the pre-existing increases as per the number of renewals with the same insurance provider over a period of few years.
Q. If my policy is not renewed in time before the expiry date, will I be denied for renewal?
Ans. The policy will be renewable provided you pay the premium within 15 days (called Grace Period) before the expiry date of the policy. However, coverage would not be available for the period for which no premium is received by the insurance company. The policy will lapse if the premium is not paid within the grace period.
Q. Can I transfer my policy from one insurance company to another without losing the renewal benefits?
Ans. No, in Pakistan there is no such policy available in which the renewal can be done with another insurance provider without losing your renewal benefits. There is a strong need in the Pakistan industry like other countries which directs the insurance companies to allow portability from one insurance company to another and from one plan to another, without making the insured lose the renewal credits for pre-existing conditions, enjoyed in the previous policy. However, this credit will be limited to the Sum Insured (including Bonus) under the previous policy. For further details and terms and conditions, an individual should contact the insurance provider and it should be subject to the insurance policy.
Q. What happens to the policy coverage after a claim is filed?
Ans. After a claim is filed and settled, the policy coverage is reduced by the amount that has been paid out on settlement. For example, in January, you start a policy with a coverage of Rs 5 Lakh for the year. In April, you make a claim of Rs 2 lakh. The coverage available to you for May to December will be the balance of Rs.3 lakh the remaining of the sum insured.
Q. What is ‘Anyone illness?
Ans. ‘Anyone illness’ would mean the continuous period of illness, including relapse within a certain number of days as specified in the policy. Usually, this is 45 days.
Q: What is the maximum number of claims allowed over a year?
Any number of claims is allowed during the policy period unless there is a specific cap prescribed in any policy. However, the sum insured is the maximum limit under the policy, if all the claims made together are equal to the sum insured the policyholder would be paid for all by the insurance provider. If the amount of claim supersedes the overall sum insured, the policyholder shall not be paid for all claims but for the ones which fall under the total insured umbrella.
Q. What is a “health check” facility?
Some health insurance policies pay for specified expenses towards general health checkups once in a few years. Normally this is available once in four years.
Q: What does it mean by Family Floater?
Family Floater is one single policy that takes care of the hospitalization expenses of your entire family. The policy has one single sum insured, which can be exploited by any/all insured persons in any proportion or amount subject to the maximum overall limit of the policy sum insured. Quite often Family floater plans are better than buying separate individual policies for each person of the family. The Floater plans to take care of all the medical expenses during sudden illness, surgeries and accidents.
If you have a grievance: The Consumer Affairs Department of Pakistan (SECP) The Securities and Exchange Commission of Pakistan (SECP) was set up in pursuance of the Securities and Exchange Commission of Pakistan Act, 1997. An individual must register their grievance first with the insurance company and in case the policyholder is not satisfied with its claim handling by the respective insurance company, the individual may escalate it to SECP. In case the policyholder is not able to access the insurer’s grievance system directly, the SECP also provides you with a gateway to register your grievance with the insurer.
Apart from registering your grievance through SECP (i.e., web), you have several channels for grievance registration through e-mail, through the letter (address your letter to Consumer Affairs Department, register your complaints/grievances against insurance companies as well as help track its status. The Call Centre or the consumer support department assists by filling up the complaints form based on the call. Wherever required, it will facilitate the filing of complaints directly with the insurance providers as the first port of call by giving information.
When a complaint is registered with SECP, it facilitates resolution by taking it up with the insurance company. The company is given a few weeks to resolve the complaint. If required, SECP also carries out investigations and enquiries. Further, wherever applicable, SECP advises the complainant to approach the Insurance Ombudsman in terms of the Redressal of Public Grievances.
What does a comprehensive health insurance policy cover?
Health insurance which is a comprehensive health insurance policy issued in the individual and small groups such as families it provides essential health benefits.
Is Corporate Health insurance, comprehensive health insurance?
For large group plans (this means for the employees of the company, regardless of the number of the employees it is purchased by the organization to facilitate the employees to ensure better productivity), there are no particular benefit requirements other than preventive care or as the company desires to make or procure a customized plan for their employees they can do so. But plans are required to provide minimum value, which means they have to cover at least 60 per cent of average costs and provide substantial coverage for inpatient care and physician services.
Another benefit of corporate health insurance is that unlike individual and retail health insurance policy the policy starts the day the organization and employer purchases health insurance that option is not available in other plans, “the policy is in effect from day-one” there is “no- waiting period” in corporate health insurance plans. If the employer chooses to provide maternity benefits to the employees then the corporate health insurance would also cover the pre-existing maternity as well for the employees of the organization.
Is COVID-19 covered in any health insurance policy?
COVID-19 added into the healthcare plan: keeping the unprecedented COVID-19 scenario in perspective, all health insurance providers in Pakistan have imbedded the COVID-19 hospitalization and the medical care needed for the said disease as a part of the health insurance policy. So now when an individual buys a health insurance policy it has an incorporated coverage for the aforementioned illness.
The same coverage is also available for corporate health insurance plans, without any added premium cost or money.
Is comprehensive health insurance coverage expensive?
Comprehensive (major medical plans) are more expensive than individual plans or any other plans available in the market which are disease-specific or certain gender-specific. It provides coverage for that certain event after which the policy lapses. While purchasing the comprehensive health care plan, a policyholder gets a sure shot coverage for any medical emergency in place of terms and conditions applied. The policy facilitates in most cases any kind of emergency and also covers accidental emergencies even during the waiting period which is mandatory and levied by the insurance provider.
How much does comprehensive health coverage cost?
The overall cost of a health insurance policy includes premiums and cost-sharing.
A premium is an amount that people pay each year for health insurance coverage. A premium is the “cover charge” for having health insurance coverage. The policyholder is responsible for this expense whether or not you visit a doctor or use any other hospital care.
Premiums of every health policy vary significantly from plan to plan. The plans are subjected to the cost (these are annual amounts, so that works out to a little more than a few hundred each month being payroll deducted for the average single employee).
Q: Which types of health insurance plans are available in Pakistan?
There are multiple health insurance plans available in the Pakistani insurance market
4. Parents care
5. Critical care
How many family members are covered in the Family health insurance plan?
The family members covered in the family health plan include husband spouse children up to 4 until 18 years of age. A child who is above the said age needs separate health insurance known as an “individual health insurance policy”.
One thing that needs to be understood is that after crossing the age of 48 an individual cannot be part of a family health plan and would need to apply for a senior health plan or parents care plan.
If there is only one parent for the family the for instance a mother or a father, they can also apply for the family health insurance, considering the parent as the guardian.
The number of family members covered can only be limited to immediate family members, husband, wife and children. Extended family members like parents and siblings cannot be covered in one procured plan.
Checklist: Choosing a health insurance plan.
Step 1: Choose your health plan marketplace
Most people with health insurance get it through an employer or by purchasing a plan themselves. If you’re one of those individuals, you won’t need to use normal insurance marketplaces. Essentially, if your company is your marketplace that is if they are providing you with health insurance or else you can purchase a plan as per your need as well.
If your employer offers health insurance and you wish to search for an alternative plan you can. But plans in the marketplace are likely to cost a lot more. This is because most companies pay for employees insurance premiums and because the health insurance plans have lower total premiums, on average.
If your work doesn’t provide health insurance, if available, you can also purchase health insurance through an insurance provider. If you choose these options, you will be eligible for premium tax benefits, which are income-based discounts on your annual premiums.
Step 2: Compare types of health insurance plans
You’ll encounter some alphabet soup while shopping; the most common types of health insurance providers such as Jubilee General, Pak Qatar Takaful, IGI, TPL and other distinguished names in the industry. The kind you choose will help determine your out-of-pocket costs and which doctors you can see and which hospitals you can choose for medical care.
While comparing plans, look for a summary of benefits. Online marketplaces of insurance usually provide a link to the summary and show the cost of the plan’s name and the coverage. A provider directory as which hospital the insurance provider has on its network, which lists the doctors and laboratories that participate in the insurance provider network, should also be available if your employer is providing you with health insurance as a workplace benefits administrator for the summary of benefits.
What about Life insurance, does it provide health Insurance Coverage?
A life insurance plan is a plan which ensures coverage for many periods and phases in your life. The plan can be a cushion for the people retiring in their 60’s or for parents saving money for their children wedding or education. Life insurance acts as saving life insurance but also providing certain health coverage in case of an accident or a permanent disability. The life insurance option also provides an option to save money which is a tax-advantaged account you can use to pay health care costs. If you’re interested in this arrangement, be sure to learn the ins and outs of life insurance plans, coverage, and benefits first.
Step 3: Compare health plan networks
An individual who can avail of cashless hospitalization can pay lower lab charges when you go to an in-network laboratory because insurance providers contract lower rates with in-network providers. When the policyholder goes out of network, those laboratories don’t have agreed-upon rates, and you’re usually on the hook for a higher portion of the cost.
If you have a preferred hospital and want to keep utilizing the medical service of the same, make sure they’re in the insurance provider networks for the plan you’re considering. You can also directly ask your insurance providers if they have a particular hospital on their network plan.
If you don’t have a preferred hospital, look for a plan with a large hospital network so you have more choices. A larger network is especially important if you live in a rural community since you’ll be more likely to find a local hospital that takes your plan. Eliminate any plans that don’t have local in-network doctors, if possible, and those with very few provider options compared with other plans.
Step 4: Compare out-of-pocket costs
Out-of-pocket costs are nearly as important as the hospitals available on the network. Any plan’s summary of benefits should clearly lay out how much you’ll have to pay out of pocket for services for instance for the labs and the doctor fee if one has to go for an out-patient checkup, generally known as OPD. The federal marketplace website offers snapshots of these costs for comparison, as do many state marketplaces.
This is where it’s useful to know a few important health insurance vocabulary words. As the consumer, your portion of costs consists of the payouts. The total you can spend out of pocket in a year is limited, and that out-of-pocket maximum is also listed in your plan information. In general, the lower your premium, the higher your out-of-pocket costs.
Your goal during this step is to narrow down choices based on out-of-pocket costs. A plan that pays a higher portion of your medical costs, but has higher monthly premiums, maybe better if:
1. You see a primary physician or a specialist frequently.
2. You frequently need emergency care.
3. You take expensive or brand-name medications regularly.
4. You are expecting a baby, plan to have a baby or have small children.
5. You have a planned surgery coming up.
6. You’ve been diagnosed with a chronic condition such as diabetes or cancer.
A plan with higher out-of-pocket costs and lower monthly premiums might be the better choice if:
1. You can’t afford the higher monthly premiums for a plan with lower out-of-pocket costs.
2. You are in good health and rarely see a doctor.
Step 5: Compare benefits
By this step, you likely have your options narrowed to just a few potential ones. To further examine it, go back to that summary of benefits to see if any of the plans cover a wider scope of services. Some may have better coverage for things like hospitalization benefits, pre and post hospitalization – medical benefits while others might have better emergency coverage and over the period better pre-existing coverage.
If the policyholder skips this quick but important step, the individual could miss out on a plan that’s much better suited to the individual and their loved ones.
Once you’re down to a couple of options, it’s time to address any lingering questions. In some cases, only speaking with a person will do, so it may be time to call the plans’ customer service lines. Write your questions down ahead of time, and have a pen or computer handy to record the answers.
Here are some examples of what you could ask:
I take a certain medication. How is that covered under this plan?
Which conditions are covered under this plan?
Are maternity medical services covered?
What happens if the policyholder gets sick when travelling abroad?
How to get started sign up, and what documents will I need?
A final tip: Don’t forget to discontinue your old plan, if you have one before the new one starts.
Checklist: Choosing a health insurance plan
Here’s a quick summary of the steps above:
Go to your marketplace and view your plan options side by side.
Decide which type of plan platinum, gold, silver or Bronze is best for you and your family and whether you want an OPD-eligible plan.
Eliminate plans that exclude the desired hospital and the care that is important to you in the insurance provider network.
One thing important to determine is whether you want more health coverage and higher premiums, or lower premiums and higher out-of-pocket costs.
Make sure any plan you choose will pay for your regular and even accidental medical care and coverage, like prescriptions and specialists.
What are the plans available for health insurance in Pakistan?
Every health insurance plan is categorized by the different coverage it provides based on how much coverage they offer. There are 5 levels of coverage you can get in a health insurance plan in Pakistan:
Jubilee Silver 2.5 lac sum insured and premium paid for family floater plan would be 8,810
Aafiyat TPL 2 lac sum insured and premium paid for family floater plan would be 4,722
EFU Silver 3 lac sum insured and premium paid for family floater plan would be 9,500
IGI Life – Silver 3 sum insured and premium paid for family floater plan would be lac 10,300
Bronze jubilee 1.25 lac sum insured and premium paid for family floater plan would be 5,080
TPL Rahat plan 1 lac sum insured and premium paid for family floater plan would be 3,583
EFU Bronze plan 1.5 lac sum insured and premium paid for an individual plan would be 7,000
IGI Bronze 1.5 lac per the sum insured and premium paid for an individual plan would be 6,700
The plans mentioned below include a rough estimate of the coverage provided by each plan and if and when required in case of an emergency, annually it may lead to this level of out-of-pocket expenses.
Bronze: You can expect to pay 40% of the costs for covered care with your plan paying 60%, these plans have the highest out-of-pocket costs with the lowest premiums.
Silver: You can expect to pay 30% of the costs for covered care with your plan paying 70%, these plans have high out-of-pocket costs with low premiums.
Gold: You can expect to pay 20% of the costs for covered care with your plan paying 80%, these plans have low out-of-pocket costs with high premiums.
Platinum: You can expect to pay 10% of the costs for covered care with your plan paying 90%, these plans have the lowest out-of-pocket costs with the highest premiums.
Titanium: It usually provides greater insured to the family or for individual plans, leading to more financial security and almost no chance of out-of-pocket expenses, if and when required in case of any medical or accidental emergency.
Accidental coverage: In addition to the different levels of coverage, every health insurance provides sum insured added some additional amount that is not included in the sum insured provided by the health insurance provider in the said plan. This coverage is designed to protect the policyholder in a worst-case scenario, hence the name “accidental” coverage. These plans have no added cost and are included in the premiums paid on health insurance.
How much does health insurance cost?
The cost for health insurance plans varies greatly depending on the type of plan and level of coverage. Even if you stay with the same health insurance plan year after year, you can expect the cost of your plan to change yearly.
What documents do I need when buying a health insurance plan?
The individual would need an original CNIC/ NICOP or a B-form to purchase the health insurance policy. The said document would have the desired details needed to procure health insurance.
The important thing to note: While buying a family health insurance the wife CNIC should have her husband name mentioned on her CNIC.
How often do I need to renew my health insurance?
The health insurance renewal is done annually, the premium is paid every year on the day the policy expires.
What is the process to renew my health insurance?
The health insurance renewal process is very simple, call the insurance provider or fill- in the form online, and pay the premium at least 24hrs before the policy expiration date.
Can I add any add-on or a child during the policy period?
No service or a child can be added during the ongoing policy period, while the policy is active for that certain period.