Find answers to frequently asked questions about the General Insurance Council here.
The term health insurance (popularly known as Medical Insurance or Mediclaim) is a type of insurance that covers your medical expenses. A health insurance policy is a contract between an insurer and an individual /group in which the insurer agrees to provide specified health insurance cover at a particular premium. The health insurer usually provides either direct payment to hospital (cashless facility) or reimburses the expenses associated with illnesses and injuries. The type and amount of health care costs that will be covered by the health plan are specified in advance. The commonest form of health insurance policies in India cover the expenses incurred on Hospitalization, though a variety of products are now available which offer a range of health covers, depending on the need and choice of the insured. The most commonly available cover takes care of the hospitalization expenses subject to maximum sum insured of the Insured in respect of the following situations: A. In case of a sudden illness or disease. B. In case of an accident. C. In case of any surgery for a disease. This insurance pays for medical care costs arising from disease or accidental injuries and depending on the terms of the health insurance policy, it could cover all or part of the medical costs of treating the disease or injury including doctor's consultation charges, surgeon’s and anesthetist’s professional charges, diagnostic tests, medicines/ consumables and nursing costs.
The contribution paid to the insurance company, or “premium” is pooled by the insurance company and the pooled amount is then used for meeting the claims of those members of the insured group who suffer from the insured event.
Hospital cash Indemnity policy - This covers the actual cost of the treatment availed for diseases ailments, accidents or ailments. The Sum insured can be utilized either at one time or for multiple admissions for one or many illnesses.
Benefit Policy - This insures to provide a fixed Sum insured in case or a medical event which was specified to be covered at the time of buying the policy. The entire sum insured is given on diagnosis and the policy expires thereafter.
Hospital Cash - This provides a fixed daily sum insured for each day of hospitalization with additional daily sum insured for named illness or surgeries. This policy is provided by Life insurers to cover for hospitalization expenses. This policy does not provide comprehensive coverage for the total expenses incurred on hospitalization.
Hospitalization policy - Specific Health plans– Critical illness
Hospitalization policy - This is typically a hospitalization cover and reimbursement of the medical expenses incurred in respect of covered disease or surgery while the insured was admitted in the hospital as a patient. Different types of medical insurances are available in the market like individual medical insurance, group medical insurance and overseas medical insurance. There are health policies that reimburse you the actual hospitalization cost for treatment of any disease and are offered by the non-life insurers only.
Specific Health Plan - This provides covers for critical illnesses or diseases such as heart attack, kidney failure, etc; most insurers offer critical illness plans. Another set of specific insurance plans target ailments such as diabetes and cancer. These plans offer cash on hospitalization, reimbursement for expenses incurred on surgical treatments, and such like.
Critical illness - Critical Illness plan insures you against the risk of serious illnesses in return of a premium you are required to pay. This gives you the same security of knowing that a guaranteed cash sum will be paid if the unexpected happens and you are diagnosed with any one of the critical illness. Sometimes a critical illness can change your lifestyle in addition to help within the home or the family. In this type of health insurance plan, the insured receives a lump sum amount within a few days of diagnosing critical illness. Once this lump sum is paid, the plan ceases to remain in force.
Group – individual- Floater
Group health insurance - Group medical insurance offers insurance cover to a group with a common trait – it may be employees of a company, members of a club or an association or members of a co-operative society etc. Many employers now provide medical insurance as a perquisite to their employees. Premium under group insurance is less than a stand-alone personal insurance policy. Discount offered depends of the size of the group. Products can be customized to the size of the group like maternity expenses are covered. Group insurance is more flexible and provides more benefits. For additional benefits, a loading is charged on the premium.
Individual Health insurance - Individual insurance covers an individual for a given premium and fixed sum insured. All the products are pre underwritten with only medicals being required after a certain age or for certain amount of sum insured.
Floater A floater is a unique plan wherein the value of sum insured opted can be used by all the members of the family or by a single-family member. Basically, the sum insured amount floats over all the members covered. For example: if the policy is bought for 3 lacs, then either all three members of the family can use Rs 1 lac each or one member can use the entire cover of 3 lacs. The specific advantages of floater plan are
The WHO, World Health Organization defines health as “Health is a state of complete physical, mental and social well being and not merely an absence of disease or infirmity.” Good Health leads to productive life, social & emotional independence. Sound Body is essential for Sound Mind and as we all know “Health is Wealth.” Actually, all of us should buy health insurance, which is appropriate to our needs. Buying health insurance protects us from the sudden, unexpected costs of hospitalization which could make a major dent into household savings .It covers the risk of financial difficulties in the event of long illness.
Health insurance can be purchased directly from any insurance company (many companies now also sell policies over the internet or through their call centers, in addition to their offices and field officials) or from authorized insurance intermediaries like insurance agents or insurance brokers. When dealing with intermediaries, please check that these intermediaries are licensed by IRDA. A list of all licensed insurance companies is available at www.irdaindia.org
The complaint and suggestion can be made with any of the bodies below: IRDA- Insurance Regulatory and Development Authority. Insurance Ombudsman – Local offices all over India
Health insurance policies are available from a sum insured of Rs 5000 in micro-insurance policies to even a sum insured of Rs 50 lakhs or more in certain critical illness plans. Most insurers do offer policies between 1 lakh to 5 lakh sum insured. As the room rents and other expenses payable by insurers are increasingly being linked to the sum insured, it is advisable to take adequate cover.
Most health insurance policies offer coverage for a duration of one year and are ordinarily renewable till a person reaches a particular age defined in his individual policy. Many non-life companies also issue policies for two, three, four and five years durations. Life insurance companies have plans which could extend for an even longer duration. As per regulations framed by the insurance regulator, IRDA, health insurance policies are ordinarily renewable unless there is any fraud, misrepresentation or moral hazard. This implies that health insurance is inherently long term.
Hospitalization expenses for admission into a hospital for a period of more than 24 hours including • Room, Boarding Expenses as provided by the Hospital/Nursing Home. • Nursing Expense. • Fees of Surgeon, Anesthetist, Medical Practitioner, Specialists, Consultants. • The cost of anesthesia, diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs, operation theatre charges, Dialysis, Chemotherapy, Radiotherapy and similar expenses. Domiciliary expenses in lieu of Hospitalization Domiciliary Hospitalization means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely: i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or ii) The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein Pre-hospitalization & Post-hospitalization expenses Relevant medical expenses incurred before and after hospitalization for a specified number of days. Relevant medical expenses means expenses related to the treatment of the disease for which the insured is hospitalized. The period varies according to the insurer and the plan opted for but usually 30 days Pre-hospitalization & 60 days Post-hospitalization expenses are covered under a typical plan. Specified Treatment cover The hospitalization in case of treatments like Dialysis, Chemotherapy, Lithotripsy, Radiotherapy, Eye surgery, Tonsillectomy, D&C taken in Hospital/Nursing Home, the time limit of 24 hours is not necessary. Special Benefits Other Special Benefits may be available under the various products of various insurers. Such benefits help offset the out of pocket expenses that occurred because of hospitalization while some provide cover for notional loss.
30 day waiting period / cooling period. No expenses are payable for first 30 days from the start of the policy except those arising out of accidents. This does not apply on subsequent continuous renewal with the company. Pre-existing diseases Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company. Pre existing diseases will be covered after a maximum of four years since the inception of the policy. Such Pre-existing diseases may be covered by the company after a period of 4 years usually but some companies and plans cover this after 1 or 2 years of continuous coverage. Specified Waiting periods Certain diseases such as cataract, piles, hernia, and sinusitis etc. are excluded for specified periods (1 or 2 years) if contracted or manifested during the currency of the policy Permanent exclusions Certain ailments diseases or conditions are never covered by the insurer like: • Injury or Diseases directly or indirectly attributable to War, Invasion, Act of Foreign Enemy, War like operations. • Cosmetic, aesthetic treatment unless arising out of accident. • Cost of spectacles, contact lenses and hearing aids • Dental treatment or surgery of any kind unless requiring hospitalization • Charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations, without any treatment. • Naturopathy or other forms of local medication • Pregnancy & childbirth related diseases • Intentional self-injury / injury under influence of alcohol, drugs • Diseases such as HIV or AIDS • Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the attending physician. • Convalescence, general debility, run-down condition or test cure, congenital external diseases or defects or anomalies, sterility, venereal disease.
The costs payable for a health insurance policy generally depends on various factors like the number of persons insured, their age group, the sum insured opted for, the cost sharing mechanisms like co-payments and deductibles in the policy, health status of the proposed insured persons, and the kind of coverage sought. The costs thus start from a subsidized premium of Rs 100 under a Universal Health Insurance Scheme policy for a person below the poverty line, and could reach upto tens of thousands for high amounts of comprehensive coverage. The data of the insurance regulator for 2007-08, however, indicates that the average premium per person was in the range of Rs 1143 per year during the year, which would comprise of a mix of group and individual policies.
• Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses. • Previous medical history is another major factor that determines the premium. If no prior medical history exists, premium will automatically be lower.. • The premium cost also depends on the work environment of the insurance buyer.. • Term of the policy helps in determining the premium, the longer the term the cheaper is the premium and vice versa. • Claim free years can also be a factor in determining the cost of the premium as it might benefit you with certain percentage of discount. This will automatically help you reduce your premium. • If you have a family, go for a Family floater policy. It is more economical and gives higher coverage for each member of the family. • Exercise regularly and follow healthy eating habits. Avoid smoking or drinking in excess. Over time all your efforts will definitely reduce your premium while covering the risk. • If you are in good health, then automatically your premium cost will be lower than the people whose have health problems.
Generally, such a checkup is required by insurers when the proposal form for a new health insurance policy indicates the need for the same, and also where insurance is sought for the first time by a person above a certain age, say 45 or 50 years, though this varies from insurer to insurer. It may also be required when the sum insured is sought to be raised at renewal time.
• Answer all questions fully and correctly in the proposal form. Where question does not apply, clearly mention that the same is not applicable. • Insurance is a contract of Utmost Good Faith requiring the Insured not only to disclose all material facts but also not to suppress any material fact in response to the questions in the proposal form. • The policy shall become void at the option of the Insurer in the event of any untrue or incorrect statement, misrepresentation, non-description or non-disclosure in any material particular in the proposal form/ personal statement, declaration and connected documents, or any material information having been withheld by the proposer or anyone acting on his behalf. • If you have any doubt or clarification on the proposal form, clarify it immediately. • Non-disclosure can also lead to rejection of a claim.
Cashless hospitalization is service provided by an insurer wherein you are not required to settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by the insurance company. However, prior approval is required from the TPA before the patient is admitted into the hospital. Cashless claims can be of two types:- Planned: Where the insured is aware of the hospitalization 2-3 days in advance. Emergency: Where the insured or any covered family member meets with sudden accident or suffers from bout of illness that requires immediate hospitalization.
• Third Party Administrator (TPA) is a service provider given to a health insurance policyholder to provide cashless facility for all hospitalizations that come under the scope of his/her Mediclaim policy. • The policy holder will have full freedom to choose the hospitals from the respective TPA’s empanelled network and utilize the services as per his choice • Insured can seek cashless facility at any of the respective TPA’s Network hospitals. • Also TPAs have ambulance referral, surgeon's referral and specialist's referral. • The in-house TPA i.e. part of the insurance company are better able to service the customer because of close synchrony with the underwriting office and because of the direct responsibility of the insurer. • A 24 X 7 assistance to all policy holders through toll free number of the TPA • Online assistance during hospitalization and filing of claim documents
A Hospital, which has an agreement with a TPA for providing Cashless treatment, is referred to as a 'Network Hospital'. Cashless facility is provided ONLY at the network hospitals. Non-network hospitals are those who have not agreed to the TPA terms and conditions and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim as per normal procedure. Along with your ID card, you will get a kit comprising of a Guide Book and List of Network Hospitals. You can also download the list from the respective TPA’s website.
In case of planned hospitalization • Contact the toll free help-line number. • Fax / submit the required documents. E.g. Doctor’s certificate, etc. • Obtain authorization for network / non-network hospitals. • Avail health treatment. • Hospital bills are directly settled by the TPA In case of emergency hospitalization • Rush the patient to the hospital • Patient avails treatment • Family contacts toll free number provided by the insurer • Family submits required documents. E.g. Doctor’s certificate, etc • Family obtains approval from the TPA • Family obtains authorization for network / non-network hospitals • Hospital bills are directly settled by the TPA
Yes it is possible to shift to another hospital for reasons of requirement of better medical procedure. However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions.
No. The TPA Card is issued to you against your health insurance policy which only covers hospitalization expenses. What are the situations under which one may be denied cashless hospitalization? • If there is any doubt in the coverage of treatment of present ailment under the Policy • If the information sent to TPA is insufficient to confirm coverage • If the ailment/condition is not being covered under the policy • If the request for pre-authorization is not received by TPA in time In such a situation, the Insured can take the treatment, pay for the treatment to the hospital and after discharge, and send the claim to TPA for processing.
In case of treatment in a non-network hospital, TPA will reimburse you the amount of bills subject to the conditions of the policy taken by the insured. The insured must ensure that the hospital where treatment is taken fulfils the conditions of definition of Hospital in the health insurance policy. TPA should be contacted within 7 days from the time of admission with the following documents in original: • Claim Form duly filled and signed by the claimant • Discharge Certificate from the hospital • All documents pertaining to the illness starting from the date it was first detected i.e. Doctor's consultation reports/history • Bills, Receipts, Cash Memos from hospital supported by proper prescription • Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics. • Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt • Attending doctor's / consultant's / specialist's / anesthetist's bill and receipt, and certificate regarding diagnosis • Details of previous policies if the details are not already with TPA
The Mediclaim Policy allows reimbursement of medical expenses incurred towards the ailment/ disease for which hospitalization was necessitated prior to hospitalization and up to a certain number of days after discharge as per the limit specified in the policy. For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to your TPA. The bills must be sent to the TPA within 7 days from the date of completion of treatment. The insured must also provide the company/TPA with additional information and assistance as may be required by the company/TPA in dealing with the claim.
The entire amount of the claim is payable, if it is within the Sum Insured and is related with the in-house treatment as per policy conditions and is supported by proper documents, except the expenses which are excluded.
Yes, the claim, which is not covered under the policy conditions, can be rejected. In case you are not satisfied by the reasons for rejection, you can represent to the insurer within 15 days of such denial.
Normally, part payments are made due to deficiency of documents or for expenses which are not covered under the policy. In case of the former if the requisite documents are made available, the claim may be considered.
You can stick to the following rules to prevent rejection of your claim: • Read the list of coverage and exclusions in policy wordings (which comes to you with the policy). • Ensure that you declare all the pre-existing diseases at the time of enrolment. • Do not claim for any hospitalization and diagnostic studies / investigation charges, which do not confirm existence of an illness or injury that requires hospitalization. • After filing your claim, make sure that you maintain minutes of your interaction with the insurer in black and white. • Understand you policy in detail. Be informed about the ‘Fine print’, exclusions and details pertaining to depreciation and deductions
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