[Deven Pabaru at a family vacation with son Parth and daughter Midushi in Mauritius in May, 2023, weeks before his wife Kajal was asked to do a stress test at the Holy Family Hospital in Mumbai. That sparked off a massive family health crisis.]
My family—wife Kajal and my two kids Parth and Midushi—and I live in a relatively quiet part of Bandra in Mumbai. We are part of a closely knit community of friends. Their children are also of the same age, go to the same school and play football and badminton together. We even go on holidays together. A little less than two years ago, a series of health emergencies engulfed our family—creating quite a panic in this peaceful and orderly lifestyle in our community of friends.
None of it was something we had even expected. Kajal was experiencing tiredness and fatigue. Starting January 2023, she went through a series of tests. In June, a stress test turned out to be positive, prompting us to take an appointment with a leading cardiac surgeon at Leelavati Hospital. He advised that we get an angiography done immediately. So we got one done at a hospital close to us. It revealed a 80 per cent blockage in the coronary artery to the heart, prompting the surgeon to recommend her for immediate angioplasty the next day. Yet, within 30 mins after she was wheeled into the operating theatre for the procedure, the surgeon discovered she had another blockage of 90% that had gone unnoticed in the angiography. Given the nature of the two blockages, the procedure couldn’t go ahead since the surgeon preferred to apply his mind on the best course of action. That eventually turned out to be a bypass surgery, or in medical parlance, a coronary artery bypass surgery (CABG). We knew it was a major surgery, but we took all this stress in our stride—and were mentally prepared for the surgery.
Except, nothing quite prepared us for the next turn of events. After about 100 days or so, Kajal complained of discomfort in the chest. Based on the scan results, the consulting cardiologist at Leelavati concluded that the surgery was unsuccessful. The blood flow in the heart remained impaired. It was a rare occurrence—and it had struck us. No one knows exactly what caused the bypass to fail. Now we were in a quandary. A friend connected us to Dr Samuel Mathew, a leading 77-year-old cardiologist based in Chennai, who was in Mumbai every two weeks. He had an incredible reputation and is known as the father of angioplasty, having treated the President of India in the past.
Fortunately for us, Dr Mathew agreed to take on the case. He carried out two separate angioplasties over the next two weeks. Each procedure took several hours to complete. In the end, Kajal had five stents placed in her heart to improve the blood flow.
More than two years have now passed since the storm that left us shaken and stirred. Kajal hasn’t faced any further challenges, but needs check-ups and tests at regular intervals to ensure that things don’t spin out of control.
If there was any silver lining in this horrendous saga, it was this: Kajal’s health emergency was a wake-up call for me and my circle of friends and family. I realised that we had paid scant attention to assessing our health risks, nor had we planned for health insurance. All this while, we knew very little about health insurance—and what’s more worrying, we didn’t seem to quite grasp the growing risks of hospitalisation and critical illness and how that could wreck havoc with family finances. As a friend averred, middle class India was one major hospitalisation away from slipping into poverty. It wasn’t an empty threat.
India faces a major healthcare challenge. We live unhealthy, sedentary lives. With an affected population of 212 million, we were already the diabetes capital of the world. According to the National Cancer Registry Programme (NCRP), there is a rising incidence of breast cancer in India. Most of these life saving treatments demand multi-speciality hospitals, costly equipment, surgeons and staff. None of that comes cheap. India is perhaps among a handful of countries where a sizeable majority—almost 70%—of India’s hospital networks is in the private sector. The cost of hospitalisation is rising. Cancer treatment can, in fact, set you back by a couple of crores. An ACKO report says that around 82 per cent of urban households in India are not covered by any health insurance and 23 per cent of hospitalisations are typically financed through borrowings.
When they got to know about our travails, the fear prompted many of our friends to rush to check their existing healthcare covers, undergo health check-ups and in many cases, increase their health covers. The key though was dealing with the mind blockers that people like us face about buying insurance. Do we really need it? What are the chances that we might actually face a health crisis? Aren’t we already adequately covered?
My personal story, therefore, has one key underlying message: buying health insurance isn’t quite as complicated as it might seem. Each of us has the intelligence to assess and manage the risks—and not allow us to be over-run by health scares. It just takes a little time and a bit of commitment to ensure that things don’t suddenly spin out of control for our families. And we don’t need to wake up after a crisis strikes us, a family member or a friend.
Q. How did I estimate how much health cover my family would need?
“A good thumb-rule is to pick a higher sum between Rs 10 lakh or 1.5 times the annual income to arrive at the amount. The age profile of the family will also dictate the total health cover you need”
This is the most common question that I get asked. I learnt that the best way to answer it was to ask yourself a set of questions. Now, it isn’t as if I had followed a well-thought through process all along. Far from it.
I was 53 when Kajal’s health emergency struck. Till then, I hadn’t applied my mind to how much health cover our family of four would need. I went about it somewhat mechanically and without too much thought.
So, twenty years ago, when Kajal and I got married, we bought two separate policies of Rs 2 lakh each. We thought that was sufficient. Even though I switched jobs from Bennett Coleman to Gillette and then to Welspun, I knew I always had access to some group insurance scheme or the other, offered by both our employers, amounting to a sum assured between Rs 10 lakh and Rs 12 lakh. And in 2010, after the birth of my daughter Midushi (my son Parth was born in 2007), we bought a family floater health insurance policy—a policy that provides medical coverage for an entire family under a single plan, allowing all covered members to share a fixed sum insured, rather than having individual policies. The policy was for Rs 5 lakh in 2011, which I increased to Rs 8 lakh in 2016.
In August 2020, in the middle of the pandemic, my insurance agent made a smart recommendation: he suggested that I buy a top-up of Rs 22 lakh to the family floater of Rs 8 lakh at a relatively low cost, with a reasonable annual premium of a little over Rs 13,000 a year. (A top-up kicks in only after the base policy is fully exhausted. And since there was no adverse health event till date, the premiums were also quite low.)
I went ahead with his suggestion—and that later saved the day for us when Kajal’s health emergency hit us in 2023.
Of course, all that changed after Kajal’s failed bypass and the attendant complications. In normal course, it would have blown a huge hole in my family finances. But it thankfully didn’t. We’ll come to that in a bit.
To arrive at a robust estimate of the sum assured, what’s a good place to start? Assess your potential risks and vulnerabilities. You’ll first need a comprehensive health check-up. If you do it every year, make sure that the results aren’t more than 90 days old. Or else, the insurance firm will ask you to do it again. Consult your trusted family physician for insights into potential risks for you and the family members. Check your family history for heart ailments, diabetes, blood pressure, cancer and asthma and at what age did they have the disease. Make a special note of any pre-existing diseases. (You’ll also need to build a digital folder of all your tests. This is important—and we’ll get to how to get that done a bit later in a separate section.)
Once you have a better handle on your risk profile, the next step is to make a more granular assessment of your hospitalisation expenses, should you need to be treated for any of the potential health risks. Most large hospital chains put up a price list online for major procedures like CABG or percutaneous transluminal coronary angioplasty (PTCA). The costs of hospitalisation tend to vary widely depending on where you are based. If you get a CABG done in Kottayam, Pune or Mumbai, the costs could vary from Rs 4 lakh to Rs 6 lakh to Rs 12 lakh, depending on the hospital you choose.
I recently had an interesting conversation with a young man in his early 30s, on the verge of getting married and keen to follow a more structured approach to buying health insurance for his family. He had no family history of any major pre-existing diseases. He said he was hale and hearty. But he seemed hung up on protecting every downside risk that he might face. He wanted to know if he should buy a cover of Rs 1 crore.
Now, here’s why it made no economic sense.
Deciding on the sum insured for the family is, after all, a sum total of many factors that I’ve outlined above. At a young age, it is improbable—not impossible though—that you will need a massive cover.
Insurance experts recommend that a safer bet is to follow the logical wealth curve as you progress through life. A good thumb-rule is to pick a higher sum between Rs 10 lakh or 1.5 times the annual income to arrive at the amount.
Of course, the age profile of the family will also dictate the total health cover you need. Older families might choose to focus on coverage for chronic and critical illnesses, and younger ones might prioritise maternity and pediatric care.
Now, going back to my situation, when we were hit with Kajal’s health emergency two years ago, I was lucky to have access to a group insurance of Rs 10 lakh offered by my employer. And once we exhausted that limit, I could lean on our family floater (plus top up) of Rs 30 lakh. Our total hospitalisation bill came to Rs 40 lakh. The insurance firm determined that my admissible claim was Rs 33 lakh. I was saved by a whisker.
However, I now have a new challenge: if I consider taking the plunge into starting up or join a smaller firm that may not to be able to offer an expensive group insurance scheme, how do I plan for the next ten years without the fallback of a group insurance policy and a new risk because of Kajal’s health situation? More on that in the next section.
Q. How did I build a customised plan for my family?
What I did:
- Assessed the family’s vulnerabilities: full check-up, medical history, lifestyle, work life?
- Estimated the possible hospitalisation expenses in my neighbourhood.
- Schooled myself in the jargon and the options: family floater or individual policies? Why? Add-ons?
- Made medical disclosures when shopping for a policy.
In June last year, with about two months to go for the renewal of my family floater, I was confronted with a new challenge. After Kajal’s health emergency the previous year, the insurance firm would no longer be immediately willing to increase the sum assured for our family floater. This was a predicament I had not foreseen. God forbid, in case things took a turn for the worse and she needed hospitalisation yet again, and I no longer had access to a corporate group insurance policy, this could make us susceptible to an even bigger risk.
I quickly realised that I could no longer coast along as I had done all these years. I doubled down to do a deep dive into my options.
I spent time—about 3-4 hours every weekend for a month—reevaluating my family’s risk/vulnerabilities on finances and health and associated costs of hospitalisation. I read up everything in at least six newspapers about the health insurance sector that I could lay my hands on, maintained a scrapbook of newspaper clippings (yes, call me old fashioned!), bought a couple of books, pored over online sites like Acko and Policy Bazaar, developed a bunch of questions for my agent, reached out to a bunch of doctor friends in India and abroad, and got myself introduced to a set of experts in the healthcare insurance space.
In the end, I was able to develop a menu of choices, based on proper research and a far better understanding of risks. That’s how I built a customised policy for my family. To be sure, that plan is still work-in-progress.
Yet, fortunately, the timing was right. And two tailwinds worked in my favour: The market for health insurance was opening up. There was suddenly a lot more choice available to people like us. So while an estimated 400 million Indians found themselves out of the ambit of health insurance, for those of us who had well paying jobs and could afford to pay for better offerings—all we had to do was overcome our inertia and apathy and take charge of our own future. I say this with all humility. No insurance agent can help you assess your risks. And invariably, mine too did not have answers to many of the questions I posed to him, even though he had served us for more than a decade (we had a different agent before that). That was the nature of the beast. I quickly realised that while an insurance agent is geared to sell, he is simply not trained to provide answers to more existential questions like:
- How much health insurance (sum assured) is enough, for today, for tomorrow, for the next 10 years?
- Which service provider could I trust, especially since this is a critical service that one may need after many years?
- How do I understand the jargon around the insurance terms and tell the difference between co-pay and co-insurance?
- Were there any useful thumb rules/heuristics around this subject?
During my research, I quickly became well-versed with a range of relatively newer options that I evaluated for my family health policy:
- Day care procedures: Many treatments do not require overnight hospitalisation. Some policies have begun offering this option.
- Critical illness cover: Few plans offer specific coverage for critical illnesses like cancer, heart disease and kidney failure. This can be a vital add on, especially in our case.
- Pre-existing disease: Nowadays, an optional cover is available for declared and accepted sets of pre-existing diseases such as asthma, diabetes, hypertension, hyperlipidemia, obesity, coronary artery disease (PTCA done, prior to one year). Earlier when you bought such a policy, the insurance firm would invariably impose a long waiting period of over 2 to 3 years before they entertained any claims to reduce any chances of fraud. The waiting period has now come down to 30-90 days for many policies.
- Worldwide cover: Available for planned hospitalisation, including in the USA and Canada. For those of us who travel abroad at least twice a year, this is an important provision, though there may still be a waiting period applicable for this cover.
- Personal accident: This option provides payment of lumpsum amount in case of accidental death, permanent total disablement (PTD) and permanent partial disablement (PPD). When I looked at my work life, I realised I was on the road. The nature of my work in the integrated logistics space meant that I was travelling across the country for 1000 km a month on an average and taking at least 6-10 flights a month. I had been doing this for more than a decade, without consciously taking into account the attendant risks.
- Voluntary co-payment: If your policy schedule offers a co-pay option, and you choose to avail of that option, you then sign up to bear a certain percentage (usually between 10% and 30%) of the admissible claim amount. This could help bring down the upfront premium, in case you opt for it. And it also increases the chances of the insurance company agreeing to take on your policy, even when there are added risks, such as in our case. Think of it as putting some skin in the game.
- Nursing at home: Here, you are entitled to a per day allowance for a specified period of days (usually 15-30 days) to avail of the medical services of a qualified nurse at home.
Alongside, it helped that our family health records were now all in one place. I was also clear that we would make all the necessary medical disclosures, not hide anything relevant, and specify existing diseases at the time of buying a new health policy. I realised from my earlier experience that this simply made the claim settlement process smoother in future.
Now, here’s how it eventually played out: I realised we had maxed out the sum assured for our family floater. We could no longer increase it. So I did the next best thing: avoid tinkering with the family floater. But in the event of a hospitalisation, we decided that Kajal would have access to all of the Rs 30 lakh, while I decided to buy a separate health policy for myself. After all, I was the main wage earner in the family. My son Parth is headed to the US for his engineering undergraduate studies this year. My daughter Midushi has three more years to complete high school. At the same time, in case I wanted to step off the corporate treadmill after almost three decades and pursue entrepreneurship, I wanted to retain that option, without compromising the family’s future. That meant investing some of our savings into better health cover for all of us.
I avoided the temptation to pluck out a random number to estimate the sum assured for my health cover. I went through a thorough process of assessing my health risks, my family medical history, my own lifestyle and work life, estimating the possible hospitalisation expenses in our catchment in Bandra using Leelavati Hospital as a benchmark and getting any check-ups done before shopping for insurance.
Now, it is easy to shortcircuit the process and avoid doing checkups. For instance, in the event that you self-declare that you don’t have diabetes, and within three months of buying the policy, it is discovered that you are diabetic (and have a family history which you chose not to disclose) and you now need to file a claim, it becomes cumbersome getting that claim passed. I wanted to consciously avoid all such complications.
Now, this is important. I realised early on that I had to exercise full control over the communication flow with the insurance firm—and not cede control to an agent. In their eagerness to close the sale, an agent tends to fill out the form many times, avoiding mentioning critical details to reduce the chances of higher premiums being charged or the customer backing out. For instance, in the past, when I had mentioned that I was an occasional smoker and enjoyed a drink or two with friends over the weekend, I discovered that the agent would choose to not mention it in the form. Later when I asked him about it, he would tell me that it would merely increase my premium. This time, I wanted to cut out all such complications arising out of wrongful disclosure and take full control of the process by dealing directly with the insurance firm.
To cut a long story short, I decided I’d opt for a sum assured of Rs 50 lakh for myself, keeping in mind all the factors I’ve described above. Yet I soon discovered that New India Assurance—with whom we had our family floater—wasn’t willing to underwrite such a large policy. My guess is that as a state-run insurer, their larger mandate was to drive penetration and make health insurance accessible to a wider number of people. They were willing to offer me a cover of Rs 25 lakh. Nothing more.
I then began to evaluate other frontline general insurers in the private sector. I considered factors like reputation and trust, asked experts, assessed claim ratios and expense ratios on the regulator IRDAI’s website and also evaluated the ease of doing business with these insurers, particularly how well their policies of buying and claim filing were digitally enabled.
I looked at a larger consideration set, to start with, and used platforms like Policy Bazaar that allowed one to compare policies, even though you could choose to buy directly from the insurer. And eventually I whittled it down to two frontline general insurers: HDFC Ergo and ICICI Lombard. Both were backed by large banks and that inspired greater confidence. Since I was well-versed with procurement processes in my line of work, I specified to both firms what I was looking for: a policy of Rs 50 lakh, supported by options of worldwide cover, personal accident insurance, day care procedure and nursing at home. I then asked for quotes from them and evaluated them on their speed of response. That’s where ICICI Lombard scored over HDFC Ergo. They were quick off the blocks. And were transparent about all the optional covers. I eventually chose a relatively new policy that ICICI Lombard had launched: Elevate, which bundled all the covers I was looking for and more.
Clearly, as I mentioned earlier, there were more optional covers now available and equally, exclusions were clearly laid out in the proposal and policy document. Besides, the policy is expressed in simple language and a conversation with my agent helped me grasp the cost/benefit equation. That way, I was able to craft a customised menu, add on optional covers after carefully evaluating it against my specific needs for my future peace of mind.
So what’s next? Now, when our family floater comes up for renewal in September, I hope to ask New India Assurance if they’d be willing to increase our cover, on the basis of no claims filed this year. If they decline—and they well might—I plan to buy a separate policy for Rs 1 crore for Kajal for the next 10 years, after clearly disclosing her pre-existing heart condition. I am, of course, willing to pay more for the optional pre-existing covers. And there’s a possibility that we may discontinue our family floater, and opt for separate policies for each of us. Parth will, in any case, need to buy a separate health insurance plan, offered by his university when he moves to the US in August. Based on the changing dynamics, I will evaluate all those options around June, like I did last year as well.
Q. How did I significantly improve the odds of getting our insurance claims cleared?
My 3 most important tips:
- Go digital for quick access to medical records and policy documents.
- Know important details: empanelled hospitals, room rent caps, claim process.
- The hospital helpdesk is the single most important touchpoint in the claim process.
In 2023, when my wife went through her cardiac operation—bypass plus angioplasty—the claim process took almost 100 days to complete. Understandably, there were a few complications due to the multiple insurance policies involved (the employers’ group insurance policy, plus our family floater). I had to escalate my claim to a grievance officer, which helped expedite the process. If that hadn’t worked, I was prepared to approach the designated independent ombudsman.
In September 2024, when my son, 17 years old, needed an emergency procedure in Kottayam, on the sidelines of a national level school football tournament he was part of, I was able to complete the entire claim process in a week.
So what helped?
Although the procedure was done at a private hospital in Kerala, I already had access to my policy documents on my smartphone. I was able to file the claim digitally with the nationalised insurance firm, with support from both my agent and the hospital helpdesk. In this case, I took the decision to avoid a cashless procedure. Or else, we would have had to delay the procedure by at least two days. My agent in Mumbai simply informed the insurance firm about the procedure. He immediately received an okay from the insurance firm and we were able to go ahead in less than an hour.
My claim of little over Rs 1 lakh was fully reimbursed, mainly because the Caritas Hospital, where the procedure was done, did the paperwork expeditiously and transparently, all on WhatsApp. Plus, on his part, the agent was responsive. And there was also the added benefit of no prior medical history in this case. And my son was discharged in four days.
My learnings: one, be aware of the room rents specified in the insurance policy so that you can choose the appropriate option at the hospital. Two, most insurance firms now have a list of empanelled hospitals which offer cashless claims. But beware, this list is subject to change. Three, it is important to understand the claim process that your insurance provider has laid out. Most of it is digitised nowadays. And a claim can be easily filed on the smartphone. And finally, make sure you’ve had a chat with the helpdesk at the hospital to ensure that your bases are well covered. They are the single most important touchpoint in any health insurance claim process.
There’s one other dimension that plays a critical role in claim processing: the ready access to your health and hospital records. More on that in the next section.
Q. How did I streamline my family’s digital health records to make life a lot simpler for me?
My best tip: Good record-keeping
"Kajal created a Google folder, scanned the papers and listed them out neatly... We now make sure that it is updated regularly every time we visit the doctor or undergo a test."
Till I renewed my family floater policy last September, I was inundated with a plethora of my wife Kajal’s health records—prescriptions, multiple test results and health check-ups, hospital discharge certificates… the paperwork stretching over a year and a half was simply mind-numbing. I had to lug around all the files every time we went for an appointment with the doctor. It got especially hairy when Kajal had to be admitted to hospital for a procedure. The hospital would ask for every scrap of information from her case history, before they could get an authorisation to go ahead with the procedure from the insurance firm. These past records were also critical in determining the complexity of the procedure—and of course, the cost. For instance, she went through multiple stenting procedures spread over two weeks. And given the sensitive nature of the operation, the consultant surgeon needed a standby surgeon. All of this adds to costs and therefore, no insurance company will clear a cashless claim without proper health records.
In August, Kajal decided to streamline all of it by digitising all the paperwork at one go. All she did was create a Google folder, scan the papers and list them out neatly. That allowed Kajal and I to have ready access to our health records, whenever we needed it. We now make sure that it is updated regularly every time we visit the doctor or undergo a test.
At one stroke, it has saved us enormous time, cut out the anxiety and stress associated with hospitalisation and responding to multiple queries and questions from the doctors, hospital staff and the insurance firms.
(Special thanks to Dr Rana Mehta, Amrita Agarwal, Sanjay Dutta, Aniruddha Sen & Rajat Jain for sharing their perspectives).
The 3 new innovations that you must know about
(And how it could impact the way you plan and buy health insurance)
Regulations spurred innovation:
Big step: In January 2024, IRDAI, the government regulator, made a serious attempt to expand coverage of a grossly underserved segment of the population: senior citizens till the age of 99.
Why it is important: Earlier, insurance firms tended to keep out anyone above the age of 55.
Impact: Now, this new regulation has forced insurance firms to bring in new innovation in emerging areas such as covers for pre-existing diseases, out patient department (OPD) hospitalisation cost, post operative care at home and worldwide cover, the longstanding demands from consumers. These are now universally available as an optional cover.
Hospitals expanding into health insurance:
Big step: Last year, Narayana Aditi, the fully owned health insurance subsidiary of Narayana Hridalaya hospital chain, has expanded into health insurance—the first hospital chain in India to do so—to serve their registered users across their catchments in 8 districts in Karnataka.
Why it is important: The lower cost of customer acquisition and availability of health records, and therefore better assessment of risk, could be a source of competitive advantage for Narayana and help its customer base gain access to reliable, cashless, affordable and quality health care and quicker processing of claims.
Impact: Too early to say, but clearly a reliable option for consumers in the relevant catchments. If the experiment is successful, it could be the basis for further expansion and provide an impetus for other frontline insurance firms. That way it eliminates the trust deficit and friction that exists between hospitals and insurance firms.
Access to new technology for better monitoring:
Big step: Insurance firms have begun driving the shift from curative to preventive health and to cash in on growing health awareness among customers.
Why it is important: Incentives for sharing health information with insurance companies: Increasingly, to encourage preventive health, offer differentiated rewards and also foster better trust between the patient and insurance firm, there are a range of measures including access to cheaper devices, such as Continuous Glucose Meters (CGMs), reward points for undergoing periodic health checkups and lower premiums, in case of a claim-free year.
Impact: This could potentially trigger win-win outcomes for the consumer, insurance firm, employers and the healthcare sector, particularly the medtech sector.
