What Is A Super Top-Up Health Insurance Policy?

What's inside? 🧐

• Introduction
• What Is A Super Top-Up Health Insurance Policy?
• How Does It Work?
• How Is It Different From A Top-Up Plan?
• Exclusions Of Super Top-Up Health Insurance
• Inclusions Of Super Top-Up Health Insurance
• Eligibility Criteria Of Super Top-Up Health Insurance
• Claim Process
• Things To Be Keep In Mind Before You Opt For Super Top-Ups
• Super Top-Up Vs Upgrading Your Policy
• Wrapping Up!

Introduction

Emergencies can knock on your door at any moment!

Ankit was enjoying a peaceful weekend with his family when suddenly, one of the members experienced severe chest pain and needed immediate medical attention. Worried and anxious, he rushes them to the nearest hospital, where the doctors diagnose a critical health condition that needs immediate intervention. As his loved one undergoes surgeries and receives specialised care, the medical expenses skyrocket to Rs 15 lakhs.

This became a challenging situation for Ankit because his base cover could meet the expenses only up to 10 lakhs. Now, he needs to arrange additional Rs 5 lakhs to pay the mounting bills. However, the situation could have been easier if he had a super top-up plan!

A super top-up plan extends the coverage of existing health insurance to provide additional financial protection in case of major medical expenses. It's a true lifesaver! It pays for hospitalisation costs only when you cross something called the ‘deductible’.

In this article, let us explore the working, benefits, and limitations of a super top-up plan to help you make an informed decision.

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What Is A Super Top-Up Health Insurance Policy?

A Super Top-Up is like an extra layer of protection that you can add to your base health insurance cover. It is an extension that steps in to pay for your medical expenses once you've used up your base plan’s coverage, known as the deductible, during the policy year.

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How Does It Work?

Super Top-Up health plans work in a straightforward manner. They provide coverage for your hospital bills up to a certain limit, beyond the deductible amount specified in the plan. This means, once you have crossed the deductible amount, the super top-up plan becomes active for any future claims.

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How Is It Different From A Top-Up Plan?

Both Super Top-up and Top-Up plans provide coverage for hospitalisation expenses. The main difference between them is how they handle claims above the deductible amount within a plan year.

In a super top-up plan, you receive coverage for all hospitalisation claims above the deductible amount throughout the policy year. On the other hand, a top-up policy only covers a single hospitalisation claim above the deductible amount within the same policy year. In other words, it covers your medical bills when the deductible limit is exhausted for every single claim.

A super top-up plan operates differently. It doesn't require you to exceed the deductible for every individual claim. Instead, all the hospitalisation costs you incur throughout the policy year are added together to calculate the super top-up deductible. Once the total cost of admission exceeds the deductible, the super top-up plan comes into effect and provides coverage for the remaining hospitalisation expenses.

Now, Let Us Understand It With An Example -  Two friends, Prakash and Udit, bought super top-up and top-up health insurance policies, respectively. They had opted for a sum insured of Rs 10 lakhs and a deductible amount of Rs 2 lakhs. However, due to subsequent hospitalisation, all of their deductible amount gets completely used up. Now, let’s see how their super top-up and top-up policies will benefit them for their future expenses within the same year.

| Super Top-up | | Top-up Deductible chosen by Prakash | 2 Lakhs | Deductible chosen by Udit | 2 Lakhs Sum Insured chosen by Prakash | 10 Lakhs | Sum insured chosen by Udit | 10 Lakhs 1st claim of the year | 4 Lakhs | 1st claim of the year | 4 Lakhs Prakash pays | 2 Lakhs. Super top-up will pay the remaining 2 Lakhs | Udit pays | 2 Lakhs. Top-up will pay the remaining 2 Lakhs 2nd claim of the year | 2 Lakhs | 2nd claim of the year | 2 Lakhs Prakash pays | Nothing. Super top-up will pay the 2 Lakhs | Udit pays | 2 Lakhs. Top-up pays nothing 3rd claim of the year | 3 Lakhs | 3rd claim of the year | 3 Lakhs Prakash pays | Nothing. Super top-up will pay the 3 Lakhs | Udit pays | 2 Lakhs. Top-up will pay the 1 Lakh

The above illustration proves that Prakash enjoys a relaxed healthcare journey with the super top-up plan. However, Udit has to pay a sum of money each year under a top-up plan. Hence, a super top-up health insurance plan is an efficient way to stay afloat in times of medical hardships.                                                                                                                                 Go to Top 🆙

Exclusions Of Super Top-Up Health Insurance

Here are some types of exclusions under super top-up health insurance -

👉Standard Permanent Exclusions

The IRDAI has established a list of 'standard permanent exclusions' that every insurance provider must follow -

• Weight Control And Obesity: Surgeries or treatments related to weight management or obesity.
• Hazardous Sports: Expenses arising from professional participation in adventurous sports like mountaineering, surfing, paragliding, etc.
• Excluded Providers: Treatment received from medical practitioners or hospitals not approved by the insurer.
• Investigation And Evaluation: Hospital admissions solely for observation or monitoring purposes.
• Rest Cure, Rehabilitation, And Respite Care: Admissions to facilities for bed rest without active medical treatment.
• Cosmetic Surgery: Procedures intended to change physical features or appearance.
• Substance Abuse: Treatments for addictive conditions like alcoholism, drug addiction, etc.
• Illegal Activities: Expenses for treating individuals involved in criminal activities or attempts.
• Gender Reassignment: Treatments aiming to change one's gender characteristics.
• Non-Prescription Substances: Costs for dietary supplements or substances not prescribed by a medical professional.
• Unverified Treatments: Surgeries or medical procedures lacking proven effectiveness.
• Domestic Treatment Facilities: Expenses incurred at health spas, nursing homes, or similar establishments primarily for domestic purposes.
• Maternity Costs: Expenses related to pre/post-natal care, childbirth hospitalisation, and related services.
• Vision Correction: Costs for correcting refractive errors up to 7.5 diopters to improve eyesight are not.
• Birth Control And Reproductive Technologies: Expenses for contraception methods, sterilisation procedures, and advanced reproductive technologies such as IVF, artificial insemination, gestational surrogacy, etc.

👉Additional Permanent Exclusions

Apart from the standard permanent exclusions outlined previously, insurers can impose additional exclusions in your policy for particular medical conditions or circumstances. If you have certain high-risk diseases or severe medical conditions, insurers may choose to permanently exclude them from your coverage. In India, insurers are authorised to apply permanent exclusions to a predefined list of illnesses as determined under the Insurance Regulatory and Development Authority of India guidelines. They are not permitted to exclude any conditions beyond this specified list.

👉Waiting Period

Waiting period is a specific time frame after purchasing the policy during which you cannot file any claims. Meaning, the insurer is not responsible for any payments related to the following expenses until the waiting period mentioned below expires.

✅Pre-Existing Disease Waiting Period

Expenses for treating a Pre-existing Disease (PED) and its direct complications are excluded until 24/36 months of continuous coverage from the policy's inception with the insurer. For sum insured enhancements, the exclusion applies again for the increased sum insured amount.

If you have had continuous coverage without any breaks as defined by the portability norms in the existing IRDAI (health insurance) regulations, the waiting period will be reduced based on the prior coverage duration.

Coverage under the policy for any pre-existing disease after the specified 24/36 months (as mentioned in the policy schedule) is contingent upon declaring it during application and the insurer's acceptance.

✅Specified Disease/Procedure Waiting Period

Expenses for treating the listed conditions and related surgeries/treatments are excluded until 24 months of continuous coverage from the policy's inception with the insurer, except for claims arising from accidents. For sum insured enhancements, the exclusion applies again for the increased sum insured

If a specified disease or procedure falls within the waiting period for pre-existing diseases, the longer waiting period will apply. The waiting period for listed conditions remains in effect regardless of whether they were contracted after the policy or declared and accepted without specific exclusions. Continuous coverage without any breaks, as defined by IRDAI's portability norms, will reduce the waiting period to the extent of prior coverage.

Below is the list of specific diseases/procedures for which a 24-month waiting period is imposed -

• Sinusitis
• Rhinitis
• Tonsillitis
• Adenoidectomy
• Mastoidectomy
• Tonsillectomy
• Tympanoplasty
• Surgery for nasal septum deviation
• Surgery for turbinate hypertrophy
• Nasal concha resection
• Nasal polypectomy
• Cysts, polyps, including breast lumps
• Polycystic ovarian diseases
• Fibromyoma
• Adenomyosis
• Endometriosis
• Prolapsed uterus
• Hysterectomy unless necessitated by malignancy
• Non-infective arthritis
• Gout and rheumatism
• Osteoporosis
• Ligament, tendon and meniscal tear
• Prolapsed intervertebral disk
• joint replacement surgery

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Inclusions Of Super Top-Up Health Insurance

Here’s what is covered under a super top-up health insurance policy -

✅Hospitalisation Cover

A top-notch super top-up health insurance plan not only helps you save money on rising costs but also brings peace of mind during emergencies for both you and your family. It covers expenses like room rentals, nursing costs, ICU fees, etc. Additionally, day-care and advanced medical procedures are included in this comprehensive policy.

✅Day-Care Procedures

This policy provides coverage for medical treatments or procedures that don't require more than 24 hours of hospitalisation, including chemotherapy, dialysis, cataract surgery, and minor surgeries conducted in a day-care facility.

✅Pre- and Post-Hospitalisation Expenses

This policy covers medical expenses both prior to and following hospitalisation, including diagnostic tests, consultations, medications, post-hospitalisation follow-up visits, etc.

✅Ambulance Charges

This policy includes coverage for ambulance services required to transport you to the hospital during a medical emergency.

✅Organ Donor Expenses

This policy provides coverage for medical expenses associated with organ transplantation, including the donor's medical expenses, hospitalisation costs, and post-operative care.

✅Domiciliary Treatments

The company covers medical expenses for domiciliary treatment if the condition requiring treatment lasts for at least three consecutive days during the policy year. The company will pay the reasonable charges for necessary medical treatment for the entire period, with a deductible.

✅Modern Treatments

The insurer will cover medical expenses during the policy year for inpatient treatment, day-care treatment, or domiciliary treatment of the following modern treatments, up to the sum insured subject to the deductible  -

• Uterine Artery Embolization and HIFU
• Balloon Sinuplasty
• Deep Brain Stimulation
• Oral chemotherapy
• Immunotherapy - Monoclonal Antibody to be given as injection vi. Intra Vitreal injections
• Robot surgeries
• Stereotactic radio surgeries
• Bronchial thermoplasty
• Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
• IONM - (Intra Operative Neuromonitoring)
• Stem Cell therapy - Hematopoietic stem cells for bone marrow transplant for haematological conditions.

✅Maternity And Newborn Care

Certain super top-up policies may offer coverage for maternity expenses, encompassing prenatal care, childbirth, and postnatal care for both the mother and newborn.

Please note that coverage may differ based on the insurer you choose.

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Eligibility Criteria Of Super Top-Up Health Insurance

Super top-up health insurance plans come with the similar eligibility criteria as with other health insurance policies. While details may vary by insurer, the main eligibility parameters include -

✅Age

Insurance providers typically set age limits for purchasing super top-up health insurance. The minimum age requirement is usually 18 years, while the maximum age limit ranges from 65 to 70 years, depending on the insurer.

✅Medical Underwriting

Applicants may need to undergo medical underwriting, where they disclose their medical history, current health status, pre-existing conditions, lifestyle habits, and previous claims history. The insurer uses this information to assess the applicant's risk and determine the premium.

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Claim Process

Claim notification with full details must be sent to the insurer under these conditions -

• Within 24 hours from the emergency hospitalisation date or before your discharge from the hospital, whichever is earlier.
• At least 48 hours prior to planned hospitalisation admission.

There are two ways to file claims - cashless claims and reimbursement claims.

👉Procedure for Cashless Claims

Here's step-by-step guide for cashless claims -

1. You can receive treatment at a hospital, subject to pre-authorization by the insurer.
2. The network provider offers a cashless request form.
3. The network provider gathers necessary information from you or the policyholder and submits a cashless facility request to the insurer for authorization.
4. After receiving the cashless request form and necessary medical information from you or the network provider, the insurer will verify and issue a pre-authorization letter to the network provider.
5. Upon discharge, you will review and sign the discharge papers along with the final bill, covering non-medical and inadmissible expenses.
6. The insurer may deny pre-authorisation if you cannot provide the necessary medical details.
7. If cashless access is denied, you can still receive treatment as advised by the treating doctor and submit the claim documents to the insurer for reimbursement.

👉Procedure for Reimbursement Claims

To get reimbursed, you need to submit the required documents to the insurer within set timeframes -

• For Hospitalisation, Day Care Treatment, or Pre-Hospitalisation Expenses: Within 30 days after hospital discharge.
• For Post-Hospitalization Expenses: Within 15 days after completing post-hospitalization treatment.

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Things To Be Keep In Mind Before You Opt For Super Top-Ups

Since a super top-up is a distinct health insurance policy, it comes with its own set conditions that you must know before opting for it -

👉 Limits For Certain Expenses

A super top-up policy comes with certain limitations. One such is the room rent limit, which refers to the specific limit up to which your insurer covers the hospital room rent. Additionally, certain expenses, such as organ donor expenses or daycare treatments, may not be covered under a super top-up plan. So, you must review all the benefits and features of the policy before making the purchase - to avoid any surprises down the lane.

👉 Separate Process For Purchase And Claims

Your base policy and super top-up insurance are two separate policies. Thus, they have separate processes for submitting applications and making claims. When it comes to purchasing a super top-up plan, you can buy it from either the same insurer as your base policy or from a different one.

To ensure a smooth and hassle-free claim process, you must purchase the super top-up plan from the same insurer as your base policy. This ensures a streamlined approach, since the insurer already has the record of your base policy details.

👉 Different Pre-Existing Waiting Period

It's important to note that the pre-existing waiting period may vary between your super top-up and base health insurance policies. The waiting period refers to a specific duration during which certain medical conditions or pre-existing diseases are excluded from coverage. Typically, the waiting period for pre-existing diseases can be up to 3 years. Therefore, discuss with your insurer to know the waiting periods applicable in your policy.

👉 Different Network Hospitals

If you purchase a super top-up policy from a different insurer than your base policy, the list of network hospitals allowing cashless payments under these policies may vary.

Note: Network hospitals are healthcare facilities that have an agreement with the insurer to provide cashless treatments.

For a smooth and convenient claims process, it is essential that you carefully review this list of network hospitals under your super top-up policy.

👉 Purchase The Super Top-Up And Base Plan Within The Same Month

Timing plays a crucial role when considering the purchase of a super top-up plan. The deductible in a super top-up policy is calculated on an annual basis. In simple terms, this means that for the super top-up coverage to kick in, your hospitalisation expenses should surpass the deductible amount within the same year.

So, to ensure a smooth and straightforward claims process, we strongly recommend buying a super top-up plan in the same month, or even better, on the same date, as your base health insurance plan. Aligning the start dates of both these policies will eliminate any potential complications - ensuring a smooth claims experience.

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Super Top-Up Vs Upgrading Your Policy

A super top-up is much cheaper when compared to a regular upgrade of your existing health insurance plan. If you use it wisely, it is an affordable way to protect yourself and your family in the long run. In fact, we would suggest you to go for a super top-up plan with your base health insurance, as it can turn out to be the best health insurance strategy for you.

Now, here's the key - You must start with a solid base cover that provides sufficient protection for your smaller hospitalisation needs. For example, at least 10 lakhs per person in the family. This base policy will take care of regular medical expenses - without having to compromise on things like room rent limits or quality of care.

But what about major medical emergencies that can cost a fortune? That's where the super top-up comes in! It is a low-cost option that can dramatically increase your coverage. You can get a super top-up of +15 lakhs or +25 lakhs, for example, which will shoulder a majority of your expenses, in case of a serious hospitalisation.

So, by combining a robust base policy with a cost-effective super top-up, you can have comprehensive protection against both planned and unplanned expenses.

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Wrapping Up!

A super top-up is a smart and cost-effective way to enhance your health insurance coverage. All you need to do is pay a decent cost and it will provide an extra layer of protection, ensuring your peace of mind. However, before taking the dive, it is important to review the policy details thoroughly - to make the right decision for yourself and your family.

If you have any further questions regarding a super top-up plan, reach out to our experts for a free 1-to-1 consultation to make a well-informed decision.