The Truth About Health Insurance: Insights from Dr. Deepak Baid, Nulife Hospital

When it comes to purchasing health insurance, most of us rely on advice from insurance agents, policy providers, or investment advisors—many of whom have a vested interest in selling a particular plan. While they often highlight the benefits, the real picture becomes clear only when a health emergency arises. That’s when policyholders encounter unexpected hurdles: certain illnesses not being covered, preferred hospitals not included in the cashless network, partial claim approvals, or outright rejections.

Unlike life insurance, buying a health insurance policy is far more complex and requires careful research and understanding. Health Insurance is not just about the premium and sum assured—it’s about knowing what’s actually covered when you need it the most.

To shed light on these challenges from the perspective of those who deal with the practical side of health insurance—hospitals and doctors—The Times of Mumbai spoke to Dr. Deepak Baid, Head of Nulife Hospital, Mumbai. As both a senior doctor and hospital administrator, Dr. Baid shares his insights into why health insurance claims are often rejected, what a good policy should truly cover, and what patients should be aware of before making a purchase.

Why is buying health insurance a wise decision in today’s world?

Healthcare is a basic necessity and should be the right of every citizen. However, healthcare is expensive and often leads to a financial crisis for families. Ideally, the government should provide healthcare, but a practical approach is to provide citizens with access to insurance that ensures quality healthcare acceptable to both patients and service providers.

What is the ideal age to buy health insurance?

As early as possible. Every family member should be insured, from newborns to the elderly.

What should one take into consideration while buying a health insurance policy?

Many companies promote insurance policies with low premiums and high sum assured, but buyers should be cautious. The track record of the insurance company is important. Some companies have high rejection rates and make arbitrary deductions. The policy should: Cover all diseases, including pre-existing conditions, pregnancy, mental health disorders, HIV, etc. Not have geographical restrictions.

Should one opt for a single-family floater policy or separate policies, especially if elderly parents are included?

A family floater policy is advisable. However, if including elderly members significantly increases the premium, it may be wiser to take a separate policy for them.

What types of illnesses should be covered under a comprehensive health insurance plan?

There should be broad coverage that includes all types of diseases, including pre-existing conditions, pregnancy, mental health disorders, HIV, and more.

Are mental illnesses now covered under health insurance policies?

Yes, as per government policy, mental illnesses must be covered by insurance companies.

Does a health insurance policy provide coverage in case of accidents or natural calamities?

Yes, emergencies and accidents are covered. Citizens should ensure that their policy also covers natural disasters.

What are the most common health issues for which health insurance claims are made?

Claims are made for a wide range of medical and surgical conditions.

What is the average cost of treatment for common serious ailments like heart attacks, liver transplants, angiography, cancer treatments, and bone marrow transplants?

Costs vary widely based on the disease, hospital, and the seniority of doctors. A basic fever treatment in a small nursing home may cost around ₹30,000 to ₹40,000. Intensive care unit (ICU) stays often cost around ₹1 lakh. Surgical packages differ depending on the condition.

Is opting for the OPD (Outpatient Department) claim facility under the policy a wise decision?

Yes, it is. Although there are challenges in claiming OPD expenses, platforms like DocSmart can help reduce costs and streamline the process for both insurers and patients.

Should a patient claim for smaller treatments like a fracture, diarrhoea, or hepatitis that require only 1–2 days of hospitalisation, or is it better to skip them?

No disease should be neglected. The treating doctor is the best person to guide whether a claim should be made.

Which option is better — cashless treatment or reimbursement (claim later)?

Cashless treatment is more convenient for citizens. However, due to the low rates offered to hospitals under cashless arrangements, the quality of treatment may be compromised compared to reimbursement.

Which health insurance service providers have the best claim settlement ratio?

Government insurance companies generally have better claim settlement records than most private insurers

However, the government should work on reducing premiums to remain competitive with private players.

What are the major reasons behind the rejection of health insurance claims?

Many claims are rejected for technical reasons related to the terms of the policy. Unfortunately, some insurance companies also reject claims to maintain profitability and manage their claim ratios.

If an insured person was a non-smoker when buying the policy but later starts smoking, should they inform the insurer?

It is not necessary. Smoking and drinking are common habits, and diseases cannot be attributed solely to them.

If an insured person develops a lifestyle disease after purchasing the policy, should they inform the insurance company?

It is not mandatory. If the disease develops after the policy was purchased and falls under the waiting period guidelines, it will be covered.

What are the common difficulties faced by citizens?

Claims rejected at one hospital may be accepted at another for the same patient and condition. Insurance coverage is often rejected when it is most needed.

Insurance companies arbitrarily delist hospitals, preventing patients from being treated by their preferred doctors. Patients often pay out-of-pocket for higher-quality care. Corporate clients are given preferential treatment over individual policyholders. Major hospitals are favored over smaller nursing homes.