Individual Coverage

By: EconomyWatch Content   Date: 8 February 2010

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Individual coverage is particularly designed for people who do not qualify for group health insurance or government-approved plans. It is also known as an individual health insurance scheme. It allows individuals to purchase health cover for themselves and their dependents from private insurers.

 

Individual Coverage Plan: Key Features

The key features of an individual coverage plan are:

 

  • Guaranteed cover for individuals, subject to their age and the pre-existing conditions clause. The policy can be renewed with the same terms and conditions.
  • Plans based on modified community rates. This means that the insurance cost for an individual coverage plan will remain the same for every consumer, regardless of gender, occupation and health status.

Scope of Individual Coverage Plan

An individual coverage plan covers expenses for:

 

  • Hospital care
  • Prenatal and maternity care
  • Immunizations and child care
  • Laboratory testing
  • Screenings such as X-ray, mammograms and CT scan.
  • Mental illness
  • Prescription drugs

 

Individual Coverage: Type of Plans

One can buy individual coverage as an indemnity plan or managed care plan from a private insurer. An indemnity plan offers the flexibility to choose any physician or hospital and file claims after the treatment is over. Here, the individual has to make payments during the treatment. In managed care, an individual can access medical facilities from a network of hospitals and physicians authorized by the insurer. Managed care plans are available in different variations, such as:

 

  • Health Maintenance Organization (HMO): Here the policyholder selects a primary health care provider from a network of hospitals and physicians approved by the insurer. The primary health care provider offers treatment for free, since he is paid by the insurance company. He may also refer the patient to specialists if required. 
  • Preferred Provider Organization (PPO): Here the policyholder can either seek treatment from the approved network of physicians or from outside the network. In the latter case, the individual is eligible to lesser medical and cost benefits.
  • Point-of-Service (POS): This is a mix of HMO and PPO plans. An individual selects the primary health care provider from a network of hospitals and physicians. However, he can also seek treatment from outside the network, if the primary healthcare provider approves.

 

An individual can also choose a basic and essential plan (B&E plan), which provides limited coverage.


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