Health Insurance offers protection in case of unexpected medical emergencies. In case of a sudden illness or accident, the health insurance policy takes care of the hospitalization, medical and other costs incurred. You need to pay a annual premium and in turn the insurer will commit to pay a predetermined sum of money to meet the claims for the period insured.
The Insurance policy takes care of pre and post-hospitalization expenses for certain injuries, illnesses, and/or diseases. As treating an illness comes at a high price, the facility of cashless settlement of claim saves you from a nightmare of arranging for money last minute.
Insurance for critical illnesses like cancer, coronary artery bypass surgery, heart attack kidney failure, multiple sclerosis etc. is provided under the critical illness plan. You pay a premium for the security of a guaranteed sum of money that will be paid if you are diagnosed with any one of the above mentioned potential killers.
Hospital cash plan are for various expenses incurred by the family members on conveyance, staying with patient, arranging special diets etc., during hospitalization due to sickness or accident. The plan pays the insured a lump sum for each day treatment as an in-patient, in any hospital. The insured is provided with a daily cash benefit for each 24 hours spent in the hospital.
An ailment for which a claim has been made already does not become a pre-existent disease if there is no break in the term of the insurance policy and it is renewed by the due date. However, the ailment becomes a pre-existent disease and exclusions will apply in the event there is a break in the term of insurance. A break of up to 7 days is allowed under certain conditions; although it may vary by company.
Health insurance will protect you and your family against any financial contingency arising due to a medical emergency.
A higher cover protects you from a medical emergency which can turn out to be a tremendous financial setback. Rising medical cost is a major deterrent; therefore, a higher cover would guarantee you a better protection.
You need to fill up an Application form with accurate medical history along with address proof. The company will get your medical test done according to the company policy.
Yes, each and every company selling Health Insurance has different schemes to fulfill all your health Insurance requirements.
An identification card is issued along with the Policy. This card would entitle you to avail cashless hospitalization facility at any of the network hospitals.
The Insurance Company would send you a renewal notice informing you of the expiry of your health policy.
No, you would not have to do so again.
Which medical tests do I need to go through?
These are a common list of medical tests that you might have to go through. The test can differ from one company to another.
1. Complete Blood count
2. Fasting Blood Sugar
3. ESR
4. Serum Creatinine
5. SGPT
6. Urine Routine
7. ECG
8. Medical Examination with BP recordings - By a physician
The Insurance Company would inform you on the medical check up routine at the time of buying a policy. The check-ups are conducted within 5 days of paying the first premium.
You can avail of premium reimbursements within 7 working days of your policy being rejected. However, the Insurance Company would not be able to reimburse your medical expenses.
Pre-existing diseases are covered subject to sub-limits and waiting period. These diseases are covered after 3-4 years provided the policy is renewed with the Insurance Company for the said period.
• Age is a critical factor for determining the cover since health risk increases with age.
• Pre-existing diseases are covered subject to sub-limits and waiting period.
No, a higher cover does not entitle you to preferential treatment. Irrespective of the insurance cover you buy, the network hospitals are responsible for quality of service
You can avail of accidental cover immediately. However ,for the first 30 days after your policy is activated you would not be entitled for any cover for sickness.
Senior Citizens are covered up to the entry age of 65 and the policy can be renewed up to 70 years of age.
Yes, Dental Treatment Expenses are covered under Outpatient Treatment but should be on medical prescription. It will vary from one Insurance Company to another
Maternity is not covered under an individual health care plan. If you and your wife are covered under a group plan by your employer, maternity benefits may be covered. Please check on this with your HR department.
Yes, you would be required to pay premium again.
At the time of purchasing a health insurance plan, you are required to fill a form stating your health history and your parent's health status. The illnesses declared at the time of filling the form are considered to be pre-existing diseases.
You can avail of the No Claim Bonus(NCB) , at the time of renewal, provided no claims are made on your previous policy.
It is important to disclose your existing health problems even if your Insurance agent might ask you to avoid mentioning them, since the insurance company is not liable to pay for any claims in case of misrepresentation of facts.
When the condition of the patient is such that she/he cannot be moved to the hospital or when there is no bed available in any of the hospitals, the treatment is administered at the patient's home. Importantly, the treatment is reimbursable under the health plan only if the treatment is comparable to that provided at a hospital or a nursing home.
Usually, the limit of compensation is low and does not apply to certain diseases, such as asthma, bronchitis, diabetes, epilepsy, etc.
There is a limit to the amount that the insurer will pay as hospital charges but is no limit as to how long a person can stay in hospital. The hospital charges or room charges are usually a proportion of sum insured.
In case of a planned hospitalization or emergency services, use your Insurance ID Card at any of the network hospitals and avail cashless service.
Planned Hospitalization: When there is a planned surgery and the patient is aware of the hospitalization 2-3 days in advance.
• Contact the TPA help-line at the numbers mentioned in your policy.
• Obtain approval from the TPA by Faxing / submitting the required documents
• Post authorization approval, patient avails treatment
• Duly completed claim form
• Doctors Prescription, surgeon's bill and receipt stating nature of operation performed.
• Original bills, receipts and discharge certificate/ card from the hospital
• Original bills from chemists
• Receipt and pathological test reports from a pathologist supported by the note from attending Medical practitioner / surgeon prescribing the test.
TPA stands for Third Party Administrator. A TPA is a specialized health service provider rendering a variety of services like networking with hospitals, arranging for hospitalisation, claim processing and documentation.
Normally, the bills are settled within 15 days of receiving the relevant documents.
If you are admitted in any of the network hospitals, you can avail cashless facility. Insurance company would directly reimburse all the admissible expenses to the hospital. However, in case of non-network hospitals, you will have to settle hospital bills at the time of discharge, and consequently, the same will be reimbursed to you by the Insurance Company.
• Carefully read the list of exclusions in policy wordings (which comes to you with the policy).
• Make sure that you have declared 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.
Once you stop paying the premiums, the policy would be discontinued.
Pre and post hospitalization expenses can be claimed. These include all medical expenses incurred 30 days before and 60 days to 90 days after hospitalization, provided they are related to the ailment/accident for which you were hospitalized.
Typically, there is a waiting period of 30 days, within which no claims by the insured are entertained by the Insurance Company. This period can vary from one company to another.
There is no limit to the number of claims per annum but there is a limit to the amount that you can claim in a year. Usually, the maximum amount that you can claim in a year is limited to the sum insured. However, special plans that provide surgical benefits and daily hospitalization cash allowance have restrictions on the amount you can claim per annum.
Yes, your health insurance policy is valid all over the country.
No, you cannot claim expenses for a cataract operation in the first year of the policy. Most insurers have a set of specific illnesses or ailments for which they will not provide cover in the first two years from the commencement of policy; however these would be covered from the third or fourth year onwards.
The exclusions include:
• Arthritis
• Benign prostate hypertrophy
• Cataract
• Dialysis required for chronic renal failure
• Dilatation & curettage
• Fistula in anus
• Gastric and duodenal ulcers
• Gout
• Hernia
• Hydrocele
• Hysterectomy unless because of malignancy
• Joint replacement (unless due to accident)
• Myomectomy
• Piles
• Rheumatism
• Sinusitis and related disorders
• Skin and all internal tumors / cysts / nodules / polyps of any kind, including breast lumps, unless malignant / adenoids and hemorrhoids
• Stone in the urinary and biliary systems
• Surgery on tonsils and sinuses
Usually, the policy would cease in the event of a claim. However, certain insurance plans offer to cover the insured for the remaining critical illnesses, at a lower sum assured and a revised insurance premium.
Expenses incurred at a hospital or a nursing home for diagnostic purposes such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are consistent with or incidental to the diagnosis and treatment of the ailment for which the policy holder has been hospitalized. In any other scenario, the insurer will not entertain claims.
A claim can be made if the hospitalization is for over 24 hours. The stay could be less than 24 hours for certain treatments, such as dialysis, chemotherapy, eye surgery, etc,
You can claim for the full sum insured, there are limits and sub-limits under the larger expense categories. There are restrictions on the room rent to 1 per cent of the sum insured and other medical expenses which can vary from one Insurance company to another.
If the sum insured is exhausted in a particular year due to large medical expenses, the insurer is not liable to bear/reimburse the insured for any further expenses.
The claim amount is paid to the nominee of the insured. If no nominee has been assigned under the policy, the insurance company will insist upon a succession certificate from a court of law for disbursing the claim amount.
Alternatively, the insurers can deposit the claim amount in the court for disbursement to the legal heirs of the deceased.
No, a part of the bill will have to be borne by the insured if it consists of the inadmissible amounts that are listed by the insurer.
The liability for paying the hospital will be on you. However, you the insurance company will reimburse the admissible amount.
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