Who are Low-Risk, Moderate-Risk and High-Risk People in Health Insurance?

Diseases are dreadful, draining conditions that not just impact an individual by deteriorating physical health but also burn a hole in one’s bank account. They never make an announcement before coming and knock you off your hard earned income which goes into paying copious medical bills. 

Since we are neither aware of such uncertainties influencing health nor well equipped to manage its financial toll on our pockets, a smart, and comprehensive health insurance policy comes to our rescue. By providing you with a strong, reliable financial buffer; a health insurance plan proves to be a boon for the policyholders and the family members who’re included in the health plan.

Who are Low-Risk, Moderate-Risk, and High-Risk People?

 As per the revised guidelines of WHO’s Guideline Development Group updated after Covid-19, following are the three broad categories of Risk groups in healthcare insurance:

• Low-Risk: It comprises the group of people who are otherwise physically healthy and at the minimum threshold of counteracting an illness or disease. This cohort has hospitalisation rate of about 0.5%
• Moderate-Risk: Those who are older than 65 years, or suffering from pre existing health conditions like obesity, diabetes, chronic obstructive pulmonary disease, cancer, kidney or liver diseases, and/or comorbidities form the section of moderate risk people. Their hospitalisation rate is around 3%
• High-Risk: People with a high risk have very weak immune systems and are considered dangerous from the perspective of a health insurance provider. They have unhealthy eating habits and lifestyle choices like addiction, substance abuse, smoking, sedentary diseases, and a strong family history of hereditary illnesses. Their estimated hospitalisation rate is near about 6%.

Characteristics Of Low, Moderate, And High Risk Individuals

As per a compiled report published after extensive scientific research by EB NMG group, following characteristic features were found in the 3 risk factions:

• Low-Risk: The low risk individuals display health issues related to minor infections or allergies like those affecting eyes, ears, throat, sprain injuries etc
• Moderate-Risk: An individual of this category could present with health conditions involving either two chronic illnesses which are in mild forms like high blood pressure (hypertension), blood sugar, thyroid, minor injuries to head region etc
• High-Risk: These people will present with one or more chronic illness in the severest forms for eg.- seizures, paralytic stroke, sensory loss, heart attack, trauma, severe lung diseases, acute kidney failure, psychiatric conditions, which might be a potential threat to self or others

Impact of Risk Levels on Health Insurance

It is important to know that every health insurance company accords ‘guarantee’  on the medical expenses based on the level and extent of financial risk involved, referred to as underwriting. Accordingly, health care plans are classified under the risk categories of low-risk, moderate-risk and high-risk. A high-risk profile is considered dangerous from the insurance provider’s perspective, and much scrutinisation is done before underwriting for such patients. To assess the impact of risk levels on their health insurance plan, insurance providers use a screening tool called health risk assessment. This assessment collects comprehensive demographic, physical, medical, and family history, including such as variables of age, gender, race, dietary habits, addictions and occupation etc. Adding on to the risk assessment task that measures the financial burden of diseases, a cost-benefit study of medical services and treatments is undertaken to reduce the monetary stress caused by them.

Factors Influencing Risk In Health Insurance Categories

The important factors that can influence your health insurance coverage are listed below:

• Age: Most health insurance companies follow a thumb rule- higher the individual’s age, higher the premium. Advanced age is one of the factors that impact health insurance because age-related diseases like diabetes, blood pressure, heart ailments and bone related diseases increase the risk on health
• Medical History: If a person has any pre-existing illness or chronic conditions, then depending on the exacerbation or level of severity, the premium insurance amount to be paid by him can shoot up as compared to a low or moderate risk person
• Lifestyle Habits: Indulging in unhealthy lifestyle choices like smoking, alcohol consumption, substance addiction and bad diet has serious health implications and it could add to your health insurance premiums. Such habits are  precipitating factors for serious illnesses and conditions 
• Body Mass Index: Individuals with a high BMI are predisposed to developing severe health conditions and chronic illnesses implying that their health insurance premiums will also be high in comparison to low or moderate risk cohort
• Geographical Location: Geodemographic research demonstrates that some   locations and regions have higher prevalence of certain medical conditions and health hazards due to climatic factors; quality of air, water and soil etc Therefore, health insurance rates are higher than others
• Occupation: Some occupations involve high health risks caused by exposure to toxic substances and environmental dangers, such as construction fields, chemical industries, firefighters, aeronautics, mining, adventure sports etc. These professions predispose a person towards contracting serious illnesses and life threatening injuries and requiring greater need of medical intervention. So, higher premiums have to be borne by an insured 
• Premium Increase: One of the most common strategies followed by health insurance companies is that they increase The premium of the health insurance plan for the high-risk people 
• Coverage Limitations: The insurance company can also impose certain coverage limits under the health insurance plan for high risk individuals. Like, if the person has chronic diabetes, he might be provided health insurance coverage but exempted from diabetes coverage and its related complications
• Rejection of coverage: In extreme cases involving the high-risk category of people, an insurance company might simply refuse to grant a health insurance plan. For example- if the person is a habitual chain smoker and has developed malignant lung cancer, coverage benefits will be curtailed

Best Ways to Purchase Health Insurance with High-Risk Profile

When buying a health insurance plan for yourself or your family members who are in the high-risk category, you should carefully browse through the coverage benefits along with the policy’s terms and conditions associated with the cover. InsuranceDekho is few steps away to assist you in purchasing your health insurance plan with the below mentioned steps:

Step 1: Enter Details 

Visit the health section of InsuranceDekho web portal. Enter the required details, such as your name, contact number, email i.d etc 

Step 2: Select From The List Of Health Plans 

Choose the most suitable and conducive health insurance plan for yourself and your family based on information which you have filled in the form 

Step 3: Online Payment

You have to furnish all the necessary details asked in Proposal Form 1; answer two health-related questions given in Proposal Form 2; then submit your KYC, and proceed to complete the online payment process

In case you have further questions related to health insurance plans for high-risk individuals, please connect with our policy experts who’re available 24*7 from Mon-Sun. Dial our toll - free number 7551196989 | or drop us an email at support@insurancedekho.com for any assistance

Conclusion

An Health insurance company, if you fall in the high-risk category, may take some safety measures. But as a customer, you should not get demotivated by these measures. Also note that as important as buying a health insurance policy, equally important it is to disclose all the health-related facts to the insurance company. This will save you from trouble at the time of claim settlement. So, better than suffering later at the time of claim, it is recommended to make complete disclosure in your proposal form.

FAQ’s Related To Risk Categories In Health Insurance

Q1. What is high-risk cover health insurance?

Ans. High-Risk Cover plan in Health insurance is the policy created to insure people who are deemed high-risk due to pre-existing medical conditions, diseases or lifestyle choices. Such high-risk health insurance policies typically have higher premium amounts and deductibles as compared to general health insurance policies.

Q2. Who must consider purchasing a high-risk cover health insurance plan in India?

Ans. Individuals with pre-existing medical conditions like high blood pressure, high diabetes, heart-related ailments, chronic kidney conditions, hereditary diseases, smokers, alcoholics etc, should consider purchasing a high-risk cover health insurance plan to secure them against exorbitant treatment expenses.

Q3. What is risk selection in health care insurance?

Ans. Risk selection, also known as underwriting, is a process that involves assessing, classifying, and selecting risks based on the parameters of insurability. Basically, it's the method insurance providers use to determine whether or not to provide coverage to a customer and at what price.

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.