Taking into account the overwhelming response to my article captioned

“Benefits for Special Needs People” in DNA on June 15, 2010 having mention of Insurance scheme Niramaya administered by The National Trust, and subsequent requests for the details of the scheme, I am giving the details of Niramaya in this article.

Niramaya is the Insurance scheme specifically designed for the “Special needs people” who are suffering from Autism, Cerebral Palsy, Mental Retardation, multiple disabilities (sclerosis) and other similar diseases. The scheme has turned out be a real boon for the family of these people who have been financially burdened with medical costs. Around 85,000 people registered under this scheme are availing the benefit of this novel group health insurance scheme. The number is still very small considering the number of people who need to benefit, and this is due to very low awareness about this scheme in general public. Thus I felt it is important that all of us contribute in our own ways to create awareness about the scheme.

Salient Features:

This scheme covers existing disease without any medical check up and no premedical check up is required for enrolling under this scheme. This scheme is unique in the sense that there is no upper or lower age limits for enrollment. The other unique feature about this scheme is that the premium charged for coverage under this scheme is uniform across all the age groups.

What it covers:

The Niramaya scheme covers overall medical expenses upto Rs. One lac within separate sub limits, besides many other expenses, which are normally not covered under regular health insurance plans like OPD treatment, regular medical check up, corrective surgery for existing disability etc. in addition to the regular expenses on hospitalization. This scheme also covers expenses incurred for transportation of the patient as well as cost of alternative medicines.

The sub limits within overall cover of Rs. One lac are given below:

The sub limits within the overall cover for Rs. 15,000 for OPD are as given below:

How to get covered

The scheme is administered by The National Trust (www.thenationaltrust.in) in collaboration with ICICI Lombard General Insurance Company Limited. The applications for this insurance scheme are accepted through registered organization which are primarily trusts and NGOs. (The area wise list of registered organizations and the enrollment forms are available on the website of the National Trust mentioned above). The applicant is required to submit the fully filled in enrollment form to the trust along with the proof of payment of applicable fee. The families Below Poverty Line (BPL) need to submit the copy of BPL card as there is no fee payable in such cases. In case they do not have BPL card, they can obtain copy of income certificate from the authority which is competent to issue the BPL card.

The enrollment can be done throughout the year but the process of covering the patients under this scheme has two cut off periods. People enrolled from 1^st September to 28^th February under first phase are covered from 2^nd April and those enrolled from 1^st March to 31^st August in second phase are covered from 2^nd October. The registered organization furnishes the details to The National Trust. The details received from the NGOs are forwarded to ICICI Lombard who in turn issues the health card, which are forwarded to the concerned registered organization through which the respective applications had come.

The application for renewal should be done well in advance accompanied with payment of proof of appropriate fee. The fee is required to be directly deposited into the account of The National Trust.

Medical screening is not insisted for enrollment under the scheme. Every beneficiary is issued a Smart/biometric cards once he/she is covered which enables him in accessing the services in empaneled hospitals.

The costs involved:

A family having income of less than Rs. 15,000 per month needs to make a payment of Rs. 250 annually for the person inflicted. Families having income of more than Rs. 15,000 per month are also eligible but the insurance premium payable would be Rs. 500 for the patient. For the BPL families, this scheme is provided free of cost as the cost is borne by the Government. .

Earlier Niramaya like other regular health insurance plans used to offer cashless facilities which have been discontinued w.e.f. 11^th March 2010 and now only offers reimbursement facilities for expenses incurred. The cashless facility will be resumed once the deficit is covered.

This way we see that Niramaya can bring ray of life to the lives of special needs people with its novel features, nominal premiums and above all the genuine intentions.

I request you to take the message across amidst your family members and acquaintances and who knows you become harbinger of lighting up a person’s life whose life is special for all of us.

Not only this you will be lending a helping hand to The National Trust to save on the publicity costs which is around 40% of the overall costs , including servicing cost of this insurance scheme.

Health care costs for hospitalization in India have risen sharply in recent years in tandem with global trends. Many a family has seen their financial planning go for a complete toss due to unexpected costs on hospitalization of a family member. Also due to increasing exposure to media there is a far bigger consciousness about medical insurance. In fact the biggest question asked to us by first time mediclaim buyers is which is the cheapest mediclaim policy?

Unfortunately if this is the only parameter used by a consumer he is likely to end up making a wrong choice. An example will illustrate this point:

If you have diabetes, would you (all other things being the same) rather buy a mediclaim policy that may be a little more expensive but will immediately cover the hospitalization expenses arising from complications connected with this disease (heart problems, kidney or eye problems associated with diabetes) without considering them as pre-existing disease rather than a comparatively cheaper policy which treats all such diseases as pre-existing and hence not immediately coverable.

The following paragraphs lays down the broad parameters apart from premium which you must compare before you buy:

1) Pre-existing disease: This is probably the most important parameter. The relevance is because if a disease is treated as pre-existing then the policy normally provides no coverage or very restricted coverage for expenditure incurred due to that disease in the immediate future. The various things to be considered under this head are

a. Definition of Pre-existing disease: Most policies provide that any disease that was present at any time in the past (including any disease which the insured person may not have been aware of) is treated as pre-existing. But some have a narrower definition, which may extend to only diseases for which the insured person had sought consultation for or was treated for or he was aware of during say the last 4 years. The narrower the definition the better it is for the consumer

b. After how many years of continuous coverage by the company will the pre-existing disease get covered: This is important as after the expiry of the cooling off period even pre-existing diseases get covered. A fine point is to find out if the company you are considering allows your track record of continuous coverage from another insurance company for the purpose of calculating this cooling off period or insists only on continuous coverage with itself for this purpose.

c. Special dispensation for diabetes/hypertension: Diabetes and hypertension have acquired epidemic status in India with one estimate putting the figure at around 5% of India’s population. Also a host of illnesses/diseases such as heart disease, kidney failure, paralysis, stroke, eye problems can trace their root cause to either diabetes or hypertension or both. Since the definition of pre-existing illness includes any complications arising there from, this has been a major reason for disputes between the mediclaim providers and the consumers in the past. Now some insurers provide immediate coverage for at least complications arising from this (ese) disease(s) even though expenses on treating the main disease itself may not be covered. If you already have diabetes/hyper tension then this is a vital consideration for you. Off course it comes at an additional cost and may also involve pre-acceptance medical tests. All these factors need to be taken into account before taking a decision.

2) Sub- limits: Sub limits mean where the overall coverage is broken down into the maximum payable for a particular kind of expense. For eg. A few insurance companies now provide that room rent cannot exceed 1% of the covered amount or that doctors/consultants fees cannot exceed 20 or 25% of the covered amount. Whilst most of these sub-limits are reasonable it is better to take a decision after being aware of them.

3) Co-Pay requirements: Quite a few companies now require that the insured bear a certain percentage of the eligible expenses either unconditionally or under certain conditions. This is called a co-pay requirement. Some companies provide a discount in premium if you agree to co-pay. Some others might want a co-pay if you choose to get treated in a non network hospital or others may have a co-pay for choosing a single air conditioned room or for getting treated in a hospital in a higher cost city. The co-pay feature is built in to ensure that the insured chooses the appropriate hospital/room/doctor level relevant to his economic status and also watches the reasonableness of the charges levied by the hospital to ensure that there is no overspend or overcharge just because of the existence of the mediclaim policy. Again there is nothing inherently unfair about this provision as long as you take a conscious decision after being aware of it.

4) Specific Exclusions: Almost all policies have general exclusions such as costs incurred for Aids/Sexually transmitted diseases or congenital diseases, etc. However some policies have specific exclusions that may be relevant to you.

5) Maximum Coverage Amount: This is important, as a particular policy that suits you may not be available for the amount of coverage that you seek.

6) Maximum age at entry: This is relevant for senior citizens as quite a few policies may not be available to them.

7) Renewability upto what age: This is relevant for senior citizens as well as people in their 50s since they need to be able to enjoy the benefit of their track record

This is not a comprehensive list of parameters by far. Each policy may have specific positive or negative features that may be relevant to you such as restricted coverage for angioplasties or certain other kind of treatments or features such as free diagnostic tests offered after a certain number of claim free years, etc.

Now presumably it is far clearer why you need to study the policy features rather than just buy the cheapest policy available. The parameters listed have been summarized in the accompanying table.

In the next article in this series I will cover the debate on whether to go in for individual policies or for a family floater policy.

So best of luck with your hunt for the most suitable mediclaim policy.