Varistha mediclaim policy — health coverage for senior citizens

The Varistha Mediclaim Policy is a one-year health insurance plan from National Insurance Company Limited, designed for senior citizens. National Insurance spells the name "Varishtha" on its own website, so search for both spellings.

A mediclaim policy reimburses the hospital bills you actually incur, up to a limit called the sum insured. The plan has two parts:

• Section I covers hospitalisation, with a sum insured of Rs. 1,00,000.
• Section II is an optional critical illness cover of Rs. 2,00,000. It pays for eight listed critical illnesses.

An admissible claim is a bill the policy agrees to pay. Many claims are processed through a third-party administrator (TPA), a company that handles claim approvals for the insurer. Your policy schedule names the TPA that serves you. 

Information updated as of 16th October

You can buy the policy if you are between 60 and 80 years old. Cover is for one person, so each spouse needs a separate policy.

First-time buyers must complete a pre-policy medical check-up. You can skip it if you have held any health insurance policy without a break for the preceding three years. The check-up includes:

• A physical examination signed by a doctor holding an MD in medicine.
• Blood sugar and urine tests.
• An echocardiogram (ECHO) of the heart.
• An eye check-up, including retinoscopy.

Reports must be dated no more than 30 days before you submit the proposal. National Insurance reimburses 50% of the check-up cost if it accepts your proposal.

Information updated as of 16th October

The policy pays for in-patient hospitalisation of at least 24 hours, domiciliary treatment at home, and more than 140 day-care procedures, on a cashless or reimbursement basis. The limits below apply to the Rs. 1,00,000 sum insured.

The policy also pays for hospital expenses for 30 days before admission and 60 days after discharge. These limits come from a third-party listing, so confirm each one in your policy wording.

Two benefits reward a clean claim record. You can take either a 5% increase in sum insured for each claim-free year, up to 50% of the sum insured, or a 5% renewal premium discount. You also get a health check-up worth up to 2% of the sum insured once every three claim-free years.

Information updated as of 16th October

The policy does not pay for outpatient (OPD) treatment, dental treatment or cosmetic surgery. National Insurance lists these exclusions under the hospitalisation cover:

• Human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and sexually transmitted diseases.
• Sterility, infertility, maternity and assisted conception.
• Intentional self-injury.
• Cosmetic or plastic surgery.
• Dental treatment.
• OPD treatment.

Broker pages add congenital defects, vaccinations, hospital stays only for diagnosis, vitamins and tonics, and spectacles or hearing aids. Check these against the policy wording.

The optional critical illness cover has its own exclusions. It does not pay for illnesses linked to non-prescribed drugs, drug addiction, smoking, suicide, HIV or AIDS, radioactivity and war. It pays only one claim for each illness, and the cover ends once the sum insured is paid.

You pay 10% of every admissible claim, except cataract and BPH claims. National Insurance's page confirms the co-payment but does not state the percentage, so the 10% comes from two broker listings. Co-payment is the share of a bill that you pay and the insurer does not.

Two options change the share:

• An optional higher co-payment of 20% (the broker listings give this figure) lowers the premium. Another listing quotes a 2% option with a 10% premium discount, so confirm which one your policy offers.

• Claims for a pre-existing disease carry an extra 10% co-payment if you paid the additional premium to cover it.

  
  

Worked example. Mr Sharma, aged 68, is admitted for a hernia repair after the first policy year. The admissible bill is Rs. 60,000.

• Co-payment: 10% × Rs. 60,000 = Rs. 6,000.
• Insurer pays: Rs. 60,000 − Rs. 6,000 = Rs. 54,000.

The example assumes the hospital charges stay within the limits in the coverage table. If the room costs more than Rs. 1,000 a day, the insurer can reduce the payout further.

The sum insured is fixed at Rs. 1,00,000 for hospitalisation and Rs. 2,00,000 for the optional critical illness cover. The sources list no higher base amount, so Rs. 1,00,000 is the ceiling for a hospital stay.

A third-party listing gives these annual premiums by age. The listing carries no date and does not say whether GST is included, so treat the figures as indicative and get a quote from National Insurance.

A lower sum insured keeps the premium low, but it also means a single long stay can use up the cover. Mr Sharma's Rs. 60,000 admissible bill from the earlier example would use 60% of his Rs. 1,00,000 sum insured in one year.

For cashless treatment, you must use a network hospital and tell the insurer or its third-party administrator before you are admitted. For reimbursement, you pay the hospital and then send your original bills for repayment.

Cashless claim

1. Choose a network hospital that the insurer or its third-party administrator has approved.
2. For a planned admission, notify the third-party administrator or insurer at least 72 hours in advance. For an emergency, notify within 24 hours of admission.
3. The hospital sends a pre-authorisation request to the third-party administrator.
4. Submit your original documents within 15 days after your post-hospitalisation treatment ends.

If the pre-authorisation is rejected, you can still get treated and file for reimbursement afterwards.

Reimbursement claim

Submit original documents within 15 days of discharge. National Insurance's page also gives a 15-day deadline counted from the end of post-hospitalisation treatment, so confirm which date applies. Keep these documents:

• Completed claim form (Part A and Part B)
• Hospital discharge summary
• Doctor's certificates and prescriptions
• Final hospital bills and receipts
• Laboratory and investigation reports, including scans and films
• Pharmacy bills and receipts

Critical illness claim

Give written notice within 15 days of diagnosis or the procedure. Send documents within 30 days after the survival period ends. The survival period is 60 days, 90 days or six months, depending on the illness. Cover starts only after a 90-day waiting period.

The renewal rules come from a broker listing, so confirm them in your policy wording:

• Pay the renewal premium within 30 days of expiry.
• To move to another insurer, apply with your policy details and claim history at least 45 days before expiry.
• You get a 15-day free-look period after buying to cancel if you do not accept the terms.

The premium qualifies for a tax deduction under Section 80D of the Income Tax Act, 1961. Your deduction limit depends on your age and the total health premium you pay in the year.

Buy it as a base cover if you are 60 or older, can accept a 10% co-payment and have no condition that needs treatment in the next 12 months. Look elsewhere if you need cover above Rs. 1,00,000 or a shorter wait for a pre-existing disease.

Before you pay, do these four things:

1. Ask National Insurance for the policy wording and read the co-payment, room rent and pre-existing disease clauses.
2. Check that your preferred hospital is on the network list.
3. Get a premium quote for your age and add the 80D deduction to your tax plan.

Don’t wait for a medical emergency to realise what’s missing.
Compare senior citizen health insurance plans with zero paperwork and instant quotes