Individual Insurance

In its health regulation, 2013, the Insurance Regulatory and Development Authority of India (IRDAI) asked individual health insurance companies to include AYUSH in their policies. (AYUSH stands for Ayurveda, yoga & naturopathy, Unani, Siddha, and homeopathy.) What this means is that insurance providers will reimburse medical expenses incurred on in-patient treatment under homeopathy, Ayurveda, Siddha, or Unani.

This post looks at the features of this AYUSH benefit in individual health insurance plans.

Eligibility

To claim the AYUSH benefit, it is necessary that the treatment takes place in a government hospital accredited by the Quality Council of India or the National Accreditation Board. In most cases, insurers cover AYUSH treatment as in-patient hospitalization. Thus, the policyholder must be hospitalized for more than a day to claim expenses under AYUSH cover.

Premium

Most insurers include AYUSH benefits in the individual health insurance policy without any significant increase in premium. In fact, this is in-built as a standard feature for most.

Expense limits

Under its AYUSH benefit, an individual health insurance company covers relevant treatment expenses. In fact, it reimburses this AYUSH expenses up to a specified limit. Historically, this limit is a percentage of the sum insured and varies from 7% to 25%. However, increasingly, insurers will cover AYUSH costs up to the entire sum assured.

No cashless benefit

Very few health insurance companies in India offer cashless options for AYUSH treatments. Therefore, insurers reimburse most claims only when the insured submits the required claim documents.

Co-payment

Some individual or group health insurance policies that offer an AYUSH benefit come with a mandatory co-payment clause. Accordingly, the policyholder has to pay a part of the admissible claim amount, and the insurer will only pay the remaining.

Double claims are not entertained

In situations where a policyholder has claimed expenses under AYUSH, they will not be able to claim expenses for the same treatment under allopathy.

Insurers only cover AYUSH treatments if included in a health insurance policy. Some insurers do not cover AYUSH at all. So, please learn about your policy before you make a purchase.

Case study: AYUSH covers only hospitalization

Ajay, a 48-year-old IT professional, suffered from chronic back pain. When nothing worked, he decided to opt for Ayurveda. The practitioner he consulted told him he would need eight sittings to treat the problem and that these would cost him Rs 50,000. Each sitting would last two hours after which Ajay would go home and return the next day.

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Ajay had comprehensive health insurance with a sum insured of Rs 5 lakh. So, he went ahead with the treatment. However, he was shocked when his insurer refused his claim. This was because the insurer covered AYUSH only for hospitalization and not for treatments taken as an OPD procedure. The insurer would have rejected the claim even in case of hospitalization because the clinic did not have government certification.

Case study: AYUSH cover with co-payment

Ravina had high blood pressure and diabetes. A friend recommended an ayurvedic treatment. She had a health insurance policy, which she carefully read to ensure that it covered ayurvedic treatment as well. Luckily, her insurance policy offered AYUSH coverage.

Ravina decided to go ahead with the treatment. She chose a government hospital accredited by the Quality Council of India.

Her total treatment cost was Rs 80,000. Her health insurance had a 20% co-payment clause. Therefore, she paid Rs 16,000, and the health insurance company settled the remaining, i.e., Rs 64,000 (80,000-16,000).

 

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