This story, first in a Mint series, dissects health insurance plans based on the ratings decided by Mint-Beshak.org. It aims to help consumers understand the salient features of each product that has made its way to the list, starting with Health AdvantEdge.
Launched in August 2022, Apex Plus Plan is the latest version of Health AdvantEdge and is renewable for the lifetime. Here is why it gets top rating.
No cap on hospital room rent and disease-specific limits
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These are the two important features in any health plan. Take for instance a health plan that has a room rent limit of ₹5,000 per day. “If the actual room cost is ₹10,000 per day, not only will the additional ₹5,000 per day have to be paid by the policyholder but the concept of proportionate deduction will also apply. In such a case where the insurer has only paid 50% of the room rent, it will also pay only 50% of each and every item in the hospital bill,” says health insurance expert Aditya Shah. What about single private AC room category? “All rooms like general wards and twin-sharing rooms can be taken without any proportionate deduction, but if you take a suite, the concept of proportionate deduction will come in, thereby limiting your claim,” says Shah.
Health AdvantEdge doesn’t have any room rent or type limit. The policy doesn’t have any disease-specific limits either. However, bariatric surgery is limited to 50% of the sum insured (SI) and comes with an upper cap of ₹10 lakh.
Waiting period
Insurance regulator Irdai has specified that the maximum waiting period for pre-existing diseases should not go beyond four years in any health policy. ICICI Lombard has capped it at just 2 years in Health AdvantEdge. Bariatric surgery is the only exception, having a waiting period of three years.
The initial waiting period during which no coverage is provided is 30 days. It is waived off in case of accidental emergencies. For critical illnesses, it is 60-90 days.
Out-patient department (OPD), day care and home care cover
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The AdvantEdge policy takes care of day care treatment that requires hospitalization of less than 24 hours. It is different from out-patient department (OPD) cover in which you visit a clinic or a hospital for diagnosis and treatment but do not get admitted.
Very few policies in India offers OPD cover for medical and dental treatment. Health AdvantEdge offers it as an optional cover that can be added by paying additional premium. The coverage differs as per the base SI. It is ₹5,000 if the base SI is ₹10 lakh and ₹50,000 in case of ₹1 crore SI. Home care treatment is in-built in the policy and allows expenses of up to 5% of base SI, up to a maximum ₹25,000.
Convalescence benefit
Very few policies in India offers convalescence benefit. Health AdvantEdge offers a lump sum ₹20,000 on continuous hospitalization for 10 days or more; payable over and above the base SI. It is available only once in a policy year.
Maternity cover
The policy offers maternity coverage on additional premium payment. It has a waiting period of just nine months, way below the industry norm. “Maternity coverage will be given only if you pay three annual premiums in one go for three policy years along with additional maternity premium. If the maternity claim does not arise during those three years, you don’t have to pay the additional premium again. However, you will still have to buy the policy in the block of three years to maintain the maternity cover,” says an ICICI Lombard spokesperson.
The policy also offers newborn baby cover, including expenses on vaccination, on additional premium payment.
SI, claim protector riders
There are interesting riders such as claim protector and SI protector. The former provides coverage for the items which are not payable under the base plan as per the list of excluded items released by Irdai such as gloves, gauze, carry bags, gowns, nebuliser and PPE kits, among others, used during hospitalization. The second type of rider protects your sum insured against rising inflation by linking the SI under the base plan to the Consumer Price index (CPI).
Worldwide cover
Hospitalization expenses incurred abroad are covered in the plan but only if a policyholder opts for an SI of ₹25 lakh and above. It will also have a co-payment of 10%. It means 10% of the claims amount will be paid by the policyholder.
Affordable premiums
As per the Mint-Beshak.org study, Health AdvantEdge premium is in line with the industry for comparable products. It is to be noted that the study analysed it for a specific risk profile ( ₹10 lakh cover for a family of two adults and one child, living in Mumbai). It may differ on a case-to-case basis.
Caveats
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There are a few features in the policy that are not a par with those of peer products. Shah says Health AdvantEdge does not offer attractive no-claim bonus (NCB) and restore benefit. The NCB is 20% of the SI every year and you can get up to 100% over the years if there is no claim. The restore benefit is triggered only once in a policy year for the same or different diseases. “Other comprehensive health plans offer better NCB and booster benefit. That said, the Health AdvantEdge premium is on the higher side. For a 30-year-old, a ₹10 lakh cover will come at an annual premium of ₹11,650, including goods and services tax (GST). Mostly, all ICICI Lombard products are priced above industry average,” says Shah.
Wellness benefit offers only up to 5% discount on renewal premium. “Health assessment, comprehensive health check-ups, gym memberships, cycling, swimming competitions and walkathons are some activities to collect wellness points,” says the ICICI Lombard spokesperson. To be sure, daily step count—a common wellness feature—is not incentivized in this plan.
The latest claims settlement ratio of the product is 99.3%, says ICICI Lombard. The company has so far sold 79,810 Health AdvantEdge plans in FY24, compared to 72,133 in FY23.