Health insurance for cardiac patients: Specialised plans help, check terms

A specialised indemnity heart policy makes sense for someone diagnosed with a coronary disease, or one who has undergone a procedure like angioplasty or bypass surgery

Heart disease is no longer only a late-life health and financial shock. It is affecting Indians in their 20s and 30s. Around one in three cardiac claims exceeds ₹1.7 lakh, and in severe cases costs cross ₹5 lakh, especially when intensive care unit (ICU) care or surgery is involved, according to Plum, an employee insurance and health benefits company.

 

“According to estimates from the Indian Council of Medical Research and World Health Organization, nearly 60-70 million Ind­ians are currently living with some form of heart disease,” says Narendra Bharindwal, president, Insurance Brokers Association of India. He adds that India sees roughly 2-2.5 million new cases annually.

 

Repercussions of early onset

 

Contracting heart disease early affects insurability. “It leads to higher underwriting scrutiny, including detailed medical tests such as treadmill test (TMT), Echo, and angiography history,” says Arun Ramamurthy, cofounder, Staywell.Health. The insured could face a waiting period of two to three years for cardiac-related claims.

 

Insurers may offer a standard health insurance policy. “But they may impose a higher premium through risk loading and waiting periods for cardiac-related claims. Policies may come with permanent exclusions for certain cardiac procedures or sub-limits on procedures like angioplasty and bypass surgery,” says Bharindwal.

 

Ramamurthy adds that premiums may increase by 30 to 80 per cent, and the co-pay clause could range from 10 to 30 per cent. If the condition is severe or recent, insurers may decline coverage for a standard health policy.

 

When a specialized policy makes sense

 

A specialised indemnity heart policy (which covers heart and other ailments and procedures as well) makes sense for someone diagnosed with a coronary disease, or one who has undergone a procedure like angioplasty or bypass surgery.

 

“Buyers may also consider a specialised cardiac policy when their proposals for a standard policy are denied, heavy premium loading is imposed, or the person wants faster and certain coverage,” says Ramamurthy. These plans may also come with a shorter waiting period.

 

How these policies work

 

Specialised heart policies are of two types: Indemnity-based and benefit-based. An indemnity-based cover reimburses hospitalisation expenses related to cardiac (and other) ailments. A fixed-benefit plan provides a lump sum payout on diagnosis. In this category, the buyer may choose either a cardiac-specific plan or a critical illness plan (which pays a benefit for a range of ailments).

 

Tighter terms and conditions

 

People who already have a cardiac condition may have to pay a higher premium for a specialised indemnity policy. The sum insured may be limited. High out-of-pocket exposure is another concern. “Pol­icyholders may end up paying from their own pocket due to sub-limits, co-pay clauses, or non-payable items,” says Shilpa Arora, cofo­under and chief operating officer (COO), Insurance Samadhan.

 

Key pre-purchase checks

 

Choose a sum insured that can absorb the full treatment cost. “If one prefers treatment in tertiary care centres or by senior cardiologists, the sum insured should be sufficient,” says Arti Mulik, chief technical officer, Universal Sompo General Insurance.  

 

Ensure that the policy does not impose restrictive sub-limits on room rent or ICU charges. Choosing the right room rent limit is crucial. “All associated medical costs increase or decrease in proportion to the type of room chosen during hospitalisation,” says Mulik.

 

Watch for disease-wise caps on cardiac treatments. Review the co-payment clause and the strength of the hospital network. “Avoid policies that look affordable upfront but come with hidden restrictions,” says Arora. Be cautious about employer-provided coverage. “They are often insufficient for serious cardiac events and may not continue if one changes jobs,” says Arora. 

Cardiac covers you may consider

 

Star Cardiac Care

• Insurer: Star Health
• Type: Indemnity 
• Sum insured: ₹3-4 lakh
• Premium: ₹16,000-₹20,000
• Nature: Cardiac-specific 
• indemnity product

 

Care Heart

• Insurer: Care Health
• Type: Indemnity
• Sum insured: Up to ₹10 lakh
• Premium: ₹20,000-₹40,000
• Nature: Covers heart patients via underwriting

 

Critical Illness

• Insurer: HDFC ERGO 
• Type: Fixed benefit
• Sum insured: ₹5-10 lakh
• Premium: ₹5,000-₹12,000
• Nature: One-time payout

 

Indicative premiums for ₹5-10 lakh sum insured at age 40. Exact premium will vary by medical history, city, and underwriting

Source: Staywell.Health

 

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The writer is a Mumbai-based independent journalist