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Health Insurance

The term ‘Health Insurance’ relates to a type of insurance that essentially covers your medical expenses. A health insurance policy like other policies isa contract between an insurer and an individual / groupin which the insurer agrees to provide specified health insurance cover at a particular “premium” subject to terms and conditions specified in the policy.

What a Health Insurance policy would normally cover
  • A Health Insurance Policy would normally cover expenses reasonably and necessarily incurred under the following heads in respect of each insured person subject to overall ceiling of sum insured (for allclaims during one policy period).
  • Room, Boarding expenses.
  • Nursing expenses.
  • Fees of surgeon, anesthetist, physician, consultants, specialists
  • Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radio therapy, cost of pace maker, Artificial limbs, cost or organs and similar expenses.
Sum Insured

The Sum Insured offered may be on an individual basis or on floater basis for the family as a whole.

Cumulative Bonus (CB)

Health Insurance policies may offer Cumulative Bonus wherein for every claim free year, the Sum Insured is increased by a certain percentage at the time of renewal subject to a maximum percentage(generally 50%). In case of a claim, CB will be reduced by 10% at the next renewal.

Minimum period of stay in Hospital

In order to become eligible to make a claim under the policy, minimum stay in the Hospital is necessary for a certain number of hours. Usually this is 24 hours. This time limit may not apply for treatment of accidental injuries and for certain specified treatments. Read the policy provision to understand the details.

Pre and post hospitalization expenses

Expenses incurred during a certain number of days prior to hospitalization and post hospitalization expenses for a specified period from the date of discharge may be considered as part of the claim provided the expenses relate to the disease /sickness. Go through the specific provision in this regard.

Cashless Facility

Insurance companies have tie-up arrangements with a network of hospitals in the country. If policy holder takes treatment in any of the network hospitals, there is no need for the insured person topay hospital bills. The Insurance Company, throug hits Third Party Administrator (TPA) will arrange direct payment to the Hospital. Expenses beyond sub limits prescribed by the policy or items not covered under the policy have to be settled by the insured direct to the Hospital. The insured can take treatment in a non-listed hospital in which case hehas to pay the bills first and then seek reimbursement from Insurance Co. There will be no cashless facility applicable here.

Exclusions

The following are generally excluded under health policies:

  • All pre-existing diseases (the pre-existingdisease exclusion is uniformly defined by all nonlifeand health insurance companies).
  • Under first year policy, any claim during the first30 days from date of cover, for sickness / disease. This is not applicable for accidental injury claims.
  • During first year of cover – cataract, Benignprostatic hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia,Hydrocele, Congenital Internal diseases, Fistulain anus, piles, sinusitis and related disorders.
  • Circumcision unless for treatment of a disease.
  • Cost of specs, contact lenses, hearing aids.
  • Dental treatment / surgery unless requiring hospitalization.
  • Convalescence, general debility, congenital external defects, V.D., intentional self-injury,use of intoxicating drugs / alcohol, AIDS,Expenses for Diagnosis, X-ray or lab tests notconsistent with the disease requiringhospitalization.
  • Treatment relating to pregnancy or child birth including cesarean section.
  • Naturopathy treatment.

The actual exclusions may vary from product toproduct and company to company. In group policies,it may possible to waive / delete the exclusions onpayment of extra premium.

No short period policies

Health insurance policies are not issued for less thanone year period.