Does your health insurance cover gym injuries? | Economic Times

I used to think that only professionals and athletes in highly competitive sports suffered serious sports injuries. An early memory of such an injury was when Mary Decker, top seed US runner, fell grievously in the 3,000 km sprint at the 1984 Los Angeles Olympics. But the truth about sports injuries struck home (literally) about two decades ago when I hurt myself playing squash in Jamshedpur. I had to immediately rush to Kolkata for a surgery and then to Hyderabad for a month-long treatment. Although I recovered well, I had no insurance to pay my costs. Fortunately, I worked for a company that picked up the expensive tab. In hindsight, I should have bought health insurance much earlier. So, my first recommendation if you do not have health insurance is to buy one right away. You may never know the surprises life will throw. Having the right kind and amount of mediclaim insurance will save considerable financial heartache. So, if you are someone who leads an active lifestyle or are a gym-goer, you should be clear about the types of sports injuries possible and which of those are insurable. Types of sports injuriesSports injuries can be of many types. A young athletic schoolgirl in my daughter's school had a major ligament tear that left her in crutches for months. Prior to the pandemic, a large cause of accidents in Delhi was children playing on trampolines at birthday parties. Injuries occur in gyms, swimming pools and playgrounds. There are instances of healthy people collapsing on treadmills. Some sports are inherently risky. A polo player I know often needs surgery because of match injuries. Fortunately, most sports injuries are mild sprains, muscle pulls and abrasions. The best way to reduce injury is to be careful. Avoid unnecessary risks. Scale up intensity gradually. Have a plan in case you are hurt. Identify hospitals that you can go to quickly and doctors that can treat you. Also, be clear about what insurance will pay for. Insurance cover of sports injuries Mediclaim insurance: Over the years the insurance regulator has significantly reduced health insurance exclusions and standardised definitions. Today, the only sports related exclusion allowed in a regular mediclaim insurance is for professional sports persons and that too in hazardous activities like racing, scuba diving or mountaineering. Most of us do not fall in this category which means that our health insurance will cover any hospitalisation or day care procedures due to injury, even if because of sports or caused in the gym. However, a key point in several mediclaim insurances is that outpatient (OPD) costs are typically not covered. This means that you will need to pay for minor strains, ligament tears, physiotherapy, and even fractures yourself even if you have a health insurance policy. The exception is if physiotherapy or OPD expenses are needed before or after hospitalisation as part of the recovery process. In those cases the cost of OPD or physiotherapy will be paid for by the health insurance company. The fact that the cost of treatment of most gym injuries is out of pocket is okay because these costs are not very high and the expenses won't pinch that much. Insurance comes in handy when the injury is more severe and requires hospitalisation. Other insurances: Other insurances such as critical illness, personal accident or overseas travel insurance do not yet have the same level of safeguards as the mediclaim insurance. These insurances have broader exclusions and more caveats in the insurance contract. For example, one insurer excluded cover in a critical illness insurance if a person was injured while participating in adventure sports and defined adventure sports broadly as any activity involving physical exertion and skill. I have paraphrased the exact policy wordings for brevity, but the essence is that the definition is broad enough to exclude any sports injury. Another insurer for overseas travel insurance excluded any bodily contact sport or potentially dangerous sport for which you are untrained. This means that injuries overseas pertaining to adventure sports like para-gliding, bungee jumping, or scuba diving are unlikely to be covered by that travel insurance company. Insuring yourselfThe first insurance that you should buy is a mediclaim insurance. All these insurances will pay for sports injuries if you are hospitalised or undertake any day care procedure. Generally, for those that live in metros, I would recommend a minimum cover of Rs 10 lakh. Such an insurance would cost about Rs 10,000 per annum as premium for a 40-year old. For those that supplement the core insurance with a critical illness or personal accident insurance, read the policy wordings carefully, particularly the provisions on sports related injuries. These contracts have other caveats as well that you should be aware of. For example, one insurer requires you to inform them if you change your occupation otherwise a claim is not payable. So, look out for these as well.Non-sports related exclusions to be mindful ofNo insurance will pay a claim if you were inebriated when the injury took place or if there is evidence of substance abuse. Another universal exclusion is cosmetic treatment. This clause came up in the case of the polo player that I mentioned earlier. He broke his jaw during a match and the insurer denied the claim on the grounds of it being cosmetic repair. I argued that the repair was not cosmetic but medically necessary. But such disputes turn out to be long processes. Similarly, illegal acts will not be paid for. For example, were you to go rafting with unlicensed operators or get hurt in a gym that does not have formal permission to operate, the claim can be denied . In fact, at the time of joining a gym you must check if they have a valid license. In case a severe injury occurs that requires hospitalisation, then the health insurance company is likely to pay your claim if you are using a gym with a valid license.I certainly do not want to curb your enthusiasm for sports and exercise because I am passionate about these myself. Dani Rojas in the award winning serial, Ted Lasso, captures the spirt eloquently when he whispers that "Football is life." But you will play a better game if you know that the risks have been taken care of. (The writer is Co-Founder www.securenow.in)