Need an air ambulance? Your health policy may not cover the full cost

Imagine a family living in a remote town in Bihar or a far-flung area in the hills. A family member falls seriously ill, but the required treatment is available only in a metro city. The family arranges an air ambulance to transport the patient to a hospital in the city. The bill comes to, say, ₹10 lakh. Will health insurance cover it?

The answer is not straightforward.

The expense will be covered only if the health insurance policy includes an air ambulance benefit. Even then, sub-limits may apply, typically ranging from ₹2.5 lakh to ₹5 lakh, including in plans that offer unlimited sum insured. Depending on the policy, this limit may be within the base sum insured or over and above it.

Ashish Kumar, founder of Delhi-based Sri Shani Financial Services, shares the case of the son of a Patna-based doctor who practises at AIIMS, Patna. The child drowned after being pushed into a swimming pool. His father immediately administered CPR and took him to AIIMS. When his condition deteriorated, he was put on a ventilator and subsequently referred to Delhi. Given his condition, road transport was not an option.

“We faced no issues with hospitalization, which was all cashless. However, we are facing issues in getting the air ambulance claim. The company has not rejected it yet, but we have been receiving queries about the veracity of the claim,” said Kumar. He spent more than ₹9 lakh on the air ambulance.

A costly clause

When buying health insurance, air ambulance cover rarely gets much attention. People may not check whether the benefit is available, let alone examine how it works. Coverage varies widely across products from the same insurer and across insurance companies.

For instance, HDFC ERGO’s Optima Secure and Optima Secure Plus provide an air ambulance benefit of up to ₹5 lakh per policy year, which is over and above the base sum insured. Its Restore plan, however, caps the coverage at ₹2.5 lakh per hospitalization. The benefit, too, is within the base sum insured.

Consider a policy with a ₹10 lakh sum insured. If hospitalization costs ₹8 lakh and the air ambulance bill is ₹2.5 lakh, only ₹2 lakh of the sum insured remains for the ambulance. The remaining ₹50,000 must be paid out of pocket. If hospitalization itself costs ₹10 lakh, nothing remains to cover the air ambulance. By contrast, if the air ambulance benefit is over and above the base sum insured, the policyholder can use the full ₹10 lakh for hospitalization and separately claim eligible air ambulance expenses, subject to the applicable limit.

Some products offer broader coverage. ICICI Lombard’s Elevate, for instance, provides air ambulance cover up to the sum insured and over and above it, but only through an add-on.

Tata AIG’s MediCare Premier has an in-built air ambulance benefit. For policies with a sum insured of up to ₹50 lakh, the benefit is capped at ₹5 lakh and is over and above the sum insured. For sums insured ranging from ₹75 lakh to ₹3 crore, the benefit can go up to ₹5 lakh when a non-network provider is used and up to the full sum insured when the provider is in the network.

How do you claim it?

Even when the policy provides air ambulance cover, getting the claim paid may require the policyholder to follow specific procedures. Some insurers accept only reimbursement claims, while others prefer cashless.

IFFCO-TOKIO General Insurance, for instance, requires prior intimation and approval. “As part of our emergency assistance service, we arrange air ambulance service through a vendor. In that sense, it is covered as cashless. If the family arranges it independently without informing us, we do not accept reimbursement claims,” said Gurmeet Singh, vice president & head of health underwriting, IFFCO-TOKIO General Insurance Company.

“If we are unable to provide an ambulance and the family arranges it itself, we will reimburse it,” he said.

He also said certain conditions need to be met. For example, under the relevant policy, the patient has to travel at least 150 km away from the address mentioned in the policy document and the stay should not be for more than 90 days, without prior notification.

At Bajaj General Insurance, air ambulance expenses are reimbursed. “We reimburse it for actual costs incurred, up to a maximum of ₹10 lakh as specified in the policy schedule. This benefit is included as part of the overall sum insured chosen under the plan,” said Vikas Gupta, head - health administration team, Bajaj General Insurance.

Care Health Insurance offers cashless treatment if the air ambulance is pre-authorised by the insurer. In a life-threatening emergency, if the insured arranges the ambulance independently, eligible costs may be reimbursed, subject to policy terms.

Families should not assume that the presence of an air ambulance benefit means they can book one and submit the bill later. Informing the insurer and understanding its protocol can be crucial.

Medical necessity

Policy documents generally require air ambulance transportation to be medically necessary because of a life-threatening emergency. A medical practitioner’s recommendation or prescription may therefore be required.

Some insurers also link the air ambulance benefit to the underlying hospitalization claim. If the hospitalization itself is not payable under the policy, the air ambulance claim may also be rejected. Singh of IFFCO-TOKIO, however, said its ambulance benefit can be paid even if the underlying hospitalization claim is not payable.

Documentation is another consideration. Care Health’s policy wording, for example, requires documents to be submitted immediately and no later than 30 days after the claim event. These include medical reports, air ambulance transportation details, the doctor’s prescription or report establishing the need for air ambulance transportation, treatment details and proof of expenses.

However, under Irdai rules, genuine claims cannot be rejected merely because they are filed after 30 days.

Travel insurance cover

A basic travel insurance policy, whether domestic or international, may not include air ambulance coverage. Gupta of Bajaj General Insurance said customers can opt for an Emergency Medical Evacuation add-on to cover both air and road ambulance services.

“This benefit applies in the event of an accidental bodily injury and ensures that if a medical emergency requires transfer to a hospital with superior facilities, the expenses for such ambulance services are covered. Transfers may be within the same city, to the insured’s hometown, or place of residence, provided the certified medical practitioner recommended the need and the company has approved the transfer in advance,” he said.

“Air ambulance coverage in domestic travel insurance will be available within India. The coverage extends overseas only in international travel insurance,” he added.

Air ambulance transportation can cost several lakh rupees, depending on the distance, aircraft, medical team and equipment required. For a family facing a medical emergency, the difference between a ₹2.5 lakh sub-limit and a benefit available up to the full sum insured can run into several lakh rupees. Checking these details is therefore particularly important for people living in smaller cities and remote areas.