How does health insurance work?

Question

and how it is usefull??? and how it is important

thanks for clearing that for me!!!

Answer 1

Basically, the insurance company looks at how healthy you are and predicts how much they might possibly have to pay out on your behalf in the future.  Based on this, they decide if they want to insure you or not insure you.  If they choose to insure you, you are charged a monthly fee called a premium.  If you have medical bills, the insurance company will cover them up to the limits on the policy.  The policy issued to you will spell out what procedures are covered, how much they will pay, how much of the bill you are expected to pay, and so on.  If you have an illness or medical condition at the time you apply for the policy, that condition is usually called a pre-existing condition and any treatment related to it will not be covered for a length of time or never covered.  (You can't expect them to pay your bills after you are already sick----that would be like trying to get car insurance after you have already wrecked your car and wanting them to pay for the repars.)

Insurance companies are in it to make a profit.  They make money by taking in more money in premiums than they pay out in benefits.  That is why premiums are so high.  EVERYONE goes to the doctor so there is a 100% chance that they will have to pay out something for everyone.  In contrast, I haven't had any claims on my car insurance in 5 years......I write them a check every 6 months so that I will be covered IF I have any accidents.  With medical insurance, it's not IF you will have medical expenses, it's WHEN and HOW MUCH.

So, it is good to have insurance.  Yes, it's expensive.  But it's not as expensive as trying to cover hundreds of thousands of dollars of hospital bills if something catastrophic happens to you.

Answer 2

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Answer 3

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Answer 4

To answer your specific questions:

1) No, health insurance is not compulsory for everyone. If you're lucky, you are able to join a group policy at work. (If you're really lucky, it's a good policy and the employer pays at least half of it.) Some states have recently made it compulsory, but that's such a recent change that there's no clear cut answer yet for how that's going to work.

2) What happens if someone can't afford it is... they don't get it, usually. Except if your income puts you below the "poverty level", in which case you qualify for Medicaid. (In some states there are programs that typically provide assistance with insuring children, though they are few and far between for covering adults.)

3) Health insurance rarely covers all the bills when you have a procedure done. Most plans cover 50-80% after you meet your deductible. The deductible amounts vary widely (but the trend is that the deductibles are getting higher and higher to keep the premiums down.) If you're really, REALLY lucky, you don't have a deductible (which is only an option on group plans), and you may only have to pay 10% of covered charges. (These plans are few and far between. As in, you might have them if you're in Congress.)

4) Yes, the patient has some say over procedures. However, if the patient opts for an "experimental" procedure, or one that isn't deemed "medically necessary", then health insurance may refuse to cover any charges at all.

In the end, as with most things, the middle class takes the brunt of these costs. This has become such a problem that more than 50% of all bankruptcies are as a result of medical bills (and of those, more than 75% had health insurance.)

** Edited to add:

It's not ALL about the money when a procedure is involved. If it is, the state keeps track of complaints filed on behalf of consumers with "managed care" (ie. any type of network arrangement including Preferred Provider Organizations, Health Maintenance Organizations, and Point of Service organizations -- also known as PPO, HMO, and POS) and may very well revoke a company's charter to do business in the state should the company be turning down too many legitimate claims.

However, insurance companies are sticklers for following the "standard" for medical care. This is what makes it difficult to answer your question. Because they should not deny anything that's considered standard for care in the given circumstances (should not and will not being two completely different things, of course.) And there may be several options that would be considered "standard." If the patient wants treatment that isn't yet considered "standard", they would balk. Period.

Answer 5

Hi, It is Nikhilesh from Jaipur. Health insurance covers your hospitality expenses, major surgical expenses. But in mediclaim policies, one thing is nagative that, there are nothing payable after policy period. Means if you fall ill and get hospitalized more then 24 hrs. then this policy covers your expenses. But i suggest u a better policy from LIC, which is health plus. It is ULIP medical insurance plan. Means your money will grow fast and you will get all mediclaim policy benefits also. So enjoy........