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Health Insurance Terms Made Easy To Understand.
In a health insurance policy, an accident is defined as any sudden event or circumstance that is unplanned, involuntary, or unforeseen. Such an event could be caused by any external, visible or violent means.
An Associated Medical Expense is a type of expense that includes various aspects covered under a medical insurance policy, such as room rent costs, RMO and nursing charges costs, operation theatre costs, doctor/surgeon/specialist/anaesthesiologist fees, etc. Expenses such as pharmacy and consumables costs, diagnostic costs and medical devices and implants costs (including artificial limb costs) are not included under Associated Medical Expenses.
An agent is a representative of a health insurance company. Such an individual serves as an intermediary between customers and insurance providers. The insurance company authorises agents to sell, promote, or offer insurance policies on their behalf. Agents also help customers understand the features and coverage provided under various general insurance plans and assist during the claim filing process.
Hospitals typically levy a high charge to transport patients to their facilities in the event of an accident or a medical emergency. Some insurers offer an ambulance cover as an additional rider, which policyholders can purchase by paying a little extra over and above their base insurance premium amount. An ambulance cover if in-built shall cover the expenses of transport of patient from hospital to home, home to hospital or hospital to hospital or as per the medical emergency.
Any one illness is defined as a continuous period of illness, including the relapse of an illness within a period of 45 days from the date of the last medical consultation at a hospital where the policyholder underwent treatment.
The IRDAI grants policyholders the option to seek alternative forms of treatment or therapy beyond the conventional allopathic treatment course. Treatments like Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) are the recognised alternative treatments policyholders can seek.
An AYUSH Hospital is defined as a healthcare facility wherein medical, surgical, and para-surgical treatment, procedures, and interventions are carried out by Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) medical practitioners. Policyholders who have purchased the AYUSH add-on rider can seek these alternative forms of treatment at central government-recognised AYUSH hospitals and colleges. Such institutions should have more than five in-patient beds, round-the-clock AYUSH practitioners on the premises, and dedicated AYUSH therapy sessions and equipment. An AYUSH Day Care Centre is typically similar to an AYUSH Hospital, but such facilities are not obligated to have in-patient beds.
The date by which a policyholder is required to renew their general insurance policies is known as the annual renewal date. Failure to renew the policy before the annual renewal date may result in the insurer suspending the policy. Insurers generally offer a one-month grace period during which policyholders can renew their policy. If the policyholder still does not renew the policy, the insurer terminates it altogether.
Insurance companies typically consider the age of policyholders while offering them coverage. For insurers, age is defined as the insured person's age as of their last birthday or age as of the policy commencement date.
Treatment forms beyond conventional allopathic treatments, such as Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH), are known as alternative treatments. Per IRDAI guidelines, insurance companies are obligated to cover the hospitalisation and associated medical costs of these above-mentioned Alternative Treatment courses, so long as the policyholder opts for the AYUSH add-on rider.
Some health insurance policies provide policyholders with a facility that enables them to restore their sum insured after it is exhausted. Policyholders can utilise the restored sums for their next hospitalisation. This benefit, typically offered as an add-on rider and provided under family floater health insurance plans, is known as Automatic Restoration.
The period during which a new policyholder is not eligible to file claims (except in case of accidents), is known as the accumulation period. Any expenses incurred by policyholders during the Accumulation Period go towards satisfying the deductible, if applicable. Generally, this period lasts for 30 days from the policy purchase date.
In health insurance policies, an assignee is an individual who receives the benefits of a particular policy.
Acute care is defined as any medical treatment or care a policyholder undergoes or receives at a recognised medical facility (like a hospital or AYUSH centre) under professional nursing care. Acute care treatments are typically temporary and not chronic.
Health care services, facilities, and items covered under a health insurance plan are known as benefits. The insurance provider defines the covered benefits and the excluded services in the policy schedule, i.e., the insurance policy documents.
In general insurance policies, the policyholder and/or the individuals or entities (trust, corporations, etc.) named as the recipients of insurance proceeds in the insurance certificate are known as beneficiaries. Beneficiaries may be eligible for financial benefits in the event of the death of the primary policyholder.
The period of time during which an insurance provider pays the benefit amount to policyholders or beneficiaries named in the insurance policy document is known as the benefit period. This clause usually appears in disability-specific health insurance policies and is sometimes called the payment period. In health insurance, the benefit period starts once the policyholder/ beneficiary is admitted into a hospital or an AYUSH centre and typically lasts for a fixed period (e.g. 45 consecutive days), per the policy terms.
Any physical harm or injury a policyholder is subjected to as a result of unexpected or unforeseen visible or violent means is referred to as a bodily injury. Examples of bodily injuries include bruises, cuts, abrasions, etc.
A broker is an individual or organisation representing an insurance buyer. Such an individual provides customers with options for various general insurance policies and suggests the best one after a comparative analysis of the policyholders' needs and financial budget. Unlike insurance agents, brokers are not employed by or representatives of a particular insurance company. They are usually insurance experts who also assist with claim filing, coverage liability, etc.
A Blanket Medical Expense is a type of health insurance expense covering the cost of any medical treatment (accidental or planned) without any exclusions. The only caveat is that policyholders can seek any medical treatment only up to a specific amount, as mentioned in the policy document.
A Bodily Injury Liability cover is a type of health insurance coverage that covers mental injury, anguish, humiliation, shock, etc., caused due to a physical injury. Such an insurance cover also compensates beneficiaries in case of death caused due an employer's negligence.
A Break in a Policy is defined as the time between the end of an existing policy's term and its extended renewal period. It is the span of time during which the policy is due for renewal, but the policyholder has not yet paid the premium to renew the policy. Typically, the break-in policy period lasts 30 days from the policy expiration date to the grace period date provided by insurers to enable policyholders to renew their policy without losing its benefits.
Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization is approved.
A Condition Precedent refers to a term or condition in a policy upon which the insurer's liability is conditional. It simply means that specific conditions or events must occur before an insurance provider is liable to fulfil the obligations listed in the policy document. In health insurance, paying a deductible is an example of a condition precedent, wherein insurers are liable to make payments only after the policyholder bears costs up to the predetermined deductible amount.
A co-payment is a specific portion of the claim amount that policyholders need to pay out of their pockets as per the policy terms. The insurance provider pays the remaining amount up to the sum insured. In co-payment, the expenses incurred are divided between policyholders and insurance providers, and the co-payment amount is usually listed as a percentage of the total admissible claims amount.
A cumulative bonus is defined as an addition or increase in the sum insured amount of a medical insurance policy. Insurance providers offer this benefit without increasing the premium amount when policyholders do not file any claims during a policy year. The cumulative bonus increases for each claim-free year in specific percentages as per the policy term. Most insurers typically offer a 50% cumulative bonus for five consecutive claim-free years.
In health insurance, coverage represents the medical costs and benefits (financial or otherwise) a health insurance provider is obligated to cover when a policyholder requires hospitalisation, treatment, or other forms of medical care, per the policy terms. Insurance companies generally mention the extent of coverage and exclusion in the health insurance policy document.
Coverage Period is defined as the period from the date an insurance policy commences up to its expiration date. It is the period of time during which a policyholder or insured party is eligible for the benefits and coverage offered under an insurance plan. Most medical insurance policies come with a standard coverage period of one year, after which the policyholder must renew the policy to receive uninterrupted coverage.
A claim is a formal request made by a policyholder to an insurance provider. A policyholder typically has to file a claim to receive compensation, reimbursement, or other associated insurance policy benefits. Policyholders must submit the necessary documents supporting their claim, including medical bills, diagnostic tests, etc. The insurance company evaluates these documents before honouring the claim.
A claim settlement ratio is a numerical metric. It helps potential insurance buyers gauge an insurance company's capacity to settle insurance claims against the number of claims received in a given financial year. The claim settlement ratio is usually expressed in percentages and includes submitted, pending, and honoured claims in a given year.
Any disease, illness, or sickness that is critical, severe, or life-threatening is regarded as a critical illness. Policyholders diagnosed with critical illnesses typically need to undergo extensive treatment, for which the treatment expenses may be significantly higher. Cancer, kidney failure, and cardiovascular problems, are common examples of critical illnesses.
A Co-morbidity refers to two or more co-existing health conditions, illnesses, or diseases diagnosed in a patient. A co-morbidity may often occur with a primary condition. For instance, a heart attack may occur with vascular disease or a stroke. Co-morbidities may also interact with each other or exist separately, e.g., a patient with high blood pressure may receive a cancer diagnosis.
A Convalescence Benefit is a cash benefit an insurance company provides to its policyholders. Insurers provide this benefit during the time a policyholder is recovering in the hospital, in case patients need to stay in the hospital for an extended period. Insurers generally offer the Convalescence Benefit in the form of a lump sum per the terms defined in the policy document.
A Critical Health Insurance Plan covers the cost of various critical illnesses like cancer, cardiovascular diseases, kidney problems, etc. These plans usually come with higher sums insured than standard health insurance policies. Customers can purchase separate critical illness insurance plans along with their standard medical insurance policy. These insurance plans come with longer waiting periods of up to 4 years.
Covid-19 Health Insurance policies are medical insurance policies launched by the Indian government after the coronavirus outbreak. Policyholders can buy these policies to bear the high cost of covid treatment. They can also choose from various Covid Health Insurance plans like the Arogya Plus Health Insurance Plan, the Arogya Premier Health Insurance Policy, the Arogya Sanjeevani Health Insurance Plan, the Covid Kavach Health Insurance Plans And the Corona Rakshak Health Insurance Policy, based on their preferred type of coverage and sum insured.
Under health insurance, a day care centre is an authorised healthcare facility within a hospital. Such a facility caters to those treatments or surgeries that require the policyholder to be hospitalised for less than 24 hours. Qualified medical practitioners carry out procedures in a fully equipped operation theatre with assistance from a nursing staff.
Medical treatments or procedures that require hospitalisation for less than 24 hours are known as day-care treatments. Patients undergoing day-care treatments or procedures are typically discharged from the clinic on the same day, soon after the minor procedure, they need to undergo. Examples of day care treatments include cataract surgery, tympanoplasty, haemodialysis, angiography, chemotherapy for cancer, etc.
A deductible is defined as a fixed amount that the insured person needs to pay from their pocket before claiming the sum insured. The health insurance provider is liable to pay for the medical costs only after the insured person has borne the costs up to the deductible amount. If the procedure costs are up to or less than the deductible amount, the insurer is not liable to make any payment.
Dependents are family members of the policyholder, for whom the policyholder generally purchases medical coverage. Under medical insurance plans, the individual purchasing the policy is typically regarded as the primary policyholder, whereas family members like the policyholder's spouse, children, parents, siblings, and parents-in-law may be listed as dependents.
Any treatment related to the insured person's teeth or structures that support their teeth is referred to as a dental treatment. Dental treatments can include dental health check-ups, fillings, extractions, endodontics (root canal treatment) and crowns. Dental treatment coverage may be part of a health insurance policy or offered as an additional rider. Such treatments are usually covered under day-care procedures.
Disclosure to Information Norm is a legal term indicating an insurance provider's right to invalidate a policyholder's health insurance policy if the policyholder provides false information or fails to disclose pre-existing conditions. In such circumstances, the policyholder has to forfeit their health insurance premiums paid to the insurance company for misrepresenting or not disclosing essential facts at the time of purchasing the policy.
Domiciliary hospitalisation is when a patient undergoes treatment at home which would otherwise require admission to a healthcare facility. Domiciliary hospitalisation is applicable when the patient cannot be moved to a hospital due to health conditions or if there is a non-availability of hospital rooms.
Disability insurance is a type of health insurance rider that covers formerly healthy policyholders who become disabled due to an accident or an illness. Such an insurance cover compensates policyholders unable to continue earning their regular income due to their disability. Under the disability insurance cover, insurance companies typically provide 80% of the income earned by the policyholder before their disability to help them pay for their daily expenses.
Any health condition, illness or injury that occurs unexpectedly and suddenly and needs immediate attention of a medical practitioner, including but not limited to hospitalisation, is referred to as Emergency Care. Health insurance policies cover Emergency Care to prevent complications such as severe long-term disability, impairment, or worse, the insured person's death.
Eligibility, also referred to as eligibility criteria, are conditions a potential health insurance buyer must satisfy to qualify for health insurance. Eligibility also refers to specific requirements policy buyers must fulfil to avail of insurance coverage for certain treatments. Typical eligibility criteria set by insurers include the policyholder's age, existing medical conditions, family history of severe health conditions, etc.
Exclusions in a health insurance policy are illnesses, ailments or treatments that the insurance provider does not cover. The policyholder must bear all the medical expenses associated with treatments or medical conditions excluded from coverage. Common examples of exclusions include cosmetic surgeries, pregnancy termination (non-emergency), self-harm leading to injuries, etc.
Eligibility Period is a term used in reference to group health insurance policies, wherein it represents the duration after which a policyholder can enjoy health insurance benefits. For instance, an employer may require employees to complete three months in their organisation before adding the latter to their group insurance plan. The eligibility period in group insurance allows employers to ascertain that the individuals in their employment are in it for the job and not just the perks.
Under a group health insurance plan, eligible employees are individuals who have fulfilled the employer's condition to avail of health insurance. For instance, a company may offer insurance benefits to its new employees after 45 days of service. In such a case, the new employees become eligible for group insurance after riding out the probationary term or waiting period.
An enhanced cumulative bonus is a monetary benefit that increases the percentage of the existing cumulative bonus, and by extension, the sum insured under a medical insurance plan. In India, health insurance providers typically enhance the cumulative bonus by 10% for every consecutive claim-free year. With the enhancement benefit, policyholders can enhance their cumulative bonus by 50% of the sum insured for five consecutive claim-free years.
The emergency medical evacuation clause comes into effect when an adequate healthcare facility is unavailable near the insured person's location. In such cases, the health insurance policy covers the cost associated with transporting the patient to the nearest available medical facility by ambulance, even if the insured party does not have an ambulance coverage add-on rider in their insurance plan.
An E-Opinion is an online second opinion a policyholder can seek from the insurance provider's panel of medical practitioners. The insured can book an appointment with a medical specialist via the insurer's website or by contacting customer support. The E-Opinion benefit is limited only to illnesses covered under the insurance plan. The policyholder can decide whether or not to act on the E-Opinion but should not hold the insurance company liable.
Insurance Fraud refers to an illegal act committed by policyholders or their insurance agents with malicious intent to deceive the insurance provider into issuing an insurance plan. If a policyholder misrepresents facts or actively conceals critical information (not disclosing pre-existing illnesses, for instance), they are said to have committed insurance fraud. In such cases, the insurance provider immediately terminates their insurance policy and black-lists the insured from obtaining insurance in future.
Individuals with any illness typically undergo various stages of diagnosis to ascertain their condition. The first diagnosis in health insurance is the first-ever medical diagnosis of an illness, disease or ailment recorded by a medical professional, based on which the individual begins the treatment process.
A family floater policy, also known as a family health insurance plan, is one that covers the medical expenses of various members of a family under a single plan. A family medical insurance plan typically covers the primary policyholder, their spouse, children and, in some cases, parents. Such policies come with a single sum insured amount, jointly shared by all insured members. It enables multiple members to seek treatment simultaneously (if necessary) and covers expenses up to the sum insured.
A free look period in health insurance is the time insurance providers allow potential customers to cancel their newly purchased health insurance policies. Insurers generally enable policyholders to terminate their policy within 10 to 15 days after its issue date. Policyholders usually use the free-look period to shop around and assess competitors offering better deals.
Medical practitioners like consultants, specialists, anaesthesiologists, surgeons etc., usually levy high fees. A health insurance policy covers these costs when a policyholder needs hospitalisation and treatment. Some of these costs are covered under cashless claims (e.g. surgeon and anaesthesiologist fees) if the policyholder chooses cashless hospitalisation. Policyholders can also claim reimbursement for fees directly paid to medical practitioners like consultants and specialists.
A family is a group comprising more than one member of a family unit. Family members covered under a health insurance plan can be legally wedded spouses, natural or legally adopted dependent children aged between three months and 25 years, and parents. Insurance companies sometimes allow policyholders to include their parents-in-law and dependent siblings under their insurance plans.
A financial endorsement is a written endorsement or request made by a policyholder that generally alters their insurance premiums. A policyholder may wish to add new members, like a spouse or a new-born baby, to the insurance plan, thus increasing the premiums. Conversely, they may want to remove deceased family members or a divorced spouse to reduce their premium. Insurers must submit a written financial endorsement request, as only the insurance provider can incorporate the requested changes.
Health insurance providers typically do not offer coverage from day one. They require policyholders to ride out an initial waiting period, also known as the first 30 days waiting period, during which the insurer is not liable to cover medical expenses. A standard health insurance policy typically has a waiting period for the first thirty days. Policyholders cannot file an insurance claim during this period, except in case of an accident.
The Grace Period is an extended period of time following a health insurance policy's renewal date. During this time, policyholders can pay their insurance premiums and renew their policies if they haven't already done so by the renewal date. Insurers allow policyholders to continue utilising their policy benefits during the grace period, which usually lasts 15 to 30 days after policy expiration.
A Group Health Insurance policy is an insurance plan that covers an organisation's members. Private corporate organisations and government entities typically purchase these insurance plans for their employees, offering it as one of the many perks of employment. The policy remains active only for the duration of employment. If a policyholder leaves the organisation, the employer terminates the policy.
A guaranteed renewal contract in a policy guarantees that the insurer does not cancel a policyholder's health insurance plan after the policyholder's health changes due to certain underlying issues. For instance, insurers may choose not to renew a policy after a policyholder is diagnosed with serious health conditions. In such cases, a guaranteed renewal contract prevents insurers from exercising the policy termination clause.
Genetic disorders are conditions prevalent in the human body due to mutation in the cell's deoxyribonucleic acid (DNA) sequence. Patients with genetic disorders typically inherit the disorders from their parents. In health insurance, genetic disorders are usually categorised under pre-existing disorders, for which the insurance terms differ from regular health insurance plans.
A grievance redressal procedure allows policyholders to raise queries with the insurance provider. Grievance redressal can be categorised into various stages. Policyholders can contact their insurer's customer care helpline, email the insurance provider, send a written appeal to the chairperson of the grievance redressal committee and, in extreme cases, approach the Insurance Regulatory Department and Authority of India (IRDAI).
General insurance comprises a wide range of insurance policies that help policyholders safeguard their various assets from damages, financial expenses, etc. Common examples of general insurance in India include Health insurance, Vehicle Insurance, Home Insurance, etc. These policies cover policyholders against financial expenses of various kinds and come with customisation benefits.
A hospital is an establishment that provides in-patient and day-care treatment of illnesses, diseases, injuries and various medical conditions. The hospital must be registered with local authorities as per the Clinical Establishments (Registration and Regulation) Act, 2010. It should be equipped with an operation theatre and at least 10-15 in-patient beds (depending on the city's population). It should have a qualified team of medical practitioners, nurses, and attendants working round the clock under its employment.
Health insurance providers offer daily hospitalisation cash benefits wherein the policyholder receives a fixed cash amount for each day they are hospitalised. The cash benefit helps policyholders bear the additional expenses not covered under health insurance and typically compensates for the ancillary expenses/ income loss during the hospitalisation period. Insurance buyers can purchase Hospital daily cash benefit as an additional rider or a standalone policy.
Hospitalisation refers to the act of seeking admission in a hospital. Per medical insurance policy terms, a policyholder is said to be hospitalised if they are admitted to a hospital for a minimum of 24 consecutive hours, i.e., in-patient treatment. Hospitalisation also includes treatment for certain day-care procedures, for which the policyholder could be hospitalised for less than 24 consecutive hours.
Medical professionals sometimes recommend patients who have undergone treatment or surgery at a hospital to continue their treatment and recovery process with Home Nursing. This facility allows patients to recuperate at home, thus saving the hospital rent and other associated costs. Most medical policies cover home nursing expenses.
Health Insurance is a contract or agreement between an insurance provider and a policyholder. The insurance provider promises to bear the expenses incurred by the policyholder up to a pre-determined amount (sum insured). The sum insured covers the medical costs if/when the policyholder needs hospitalisation or medical care. The insurance provider enlists the various diseases, treatments and surgeries covered and the exclusions in the health insurance policy contract.
Health Cover is an insurance company's liability to pay a policyholder the sum insured to cover the medical expenses resulting from hospitalisation and treatment. The health cover allows policyholders to seek treatment for illnesses and diseases covered under the health insurance contract. A health cover typically includes medical diagnosis costs, surgery expenses, hospital rent, ambulance charges, hospital cash allowance, etc.
A Health Maintenance Organisation (HMO) is a type of medical insurance plan wherein the insurer has tie-ups with a network of healthcare professionals. The HMO plan covers expenses incurred when the insured person receives medical care from the network group only, except for medical emergencies like accidents.
Health Insurance Tax Benefits are tax-liability-reducing benefits that a policyholder is eligible for under Section 80D of the Income Tax Act, 1961. Health insurance buyers may claim an annual tax deduction of up to Rs 25,000 for purchasing health insurance for self, spouse and dependent children. They can claim an additional Rs 50,000 in deductions for buying senior citizen health insurance for parents aged 60 years and above. Depending on their age, policy buyers can claim Rs 25,000 to Rs 100,000 per annum as health insurance tax benefits.
Hospital Indemnity is a type of health insurance plan that covers the actual medical cost subject to deductibles, co-payment or other expenses. Hospital indemnity is distinctive to most regular health insurance plans. In the case of critical health insurance plans, instead of hospital indemnity, the insured person receives a lump-sum amount of the sum insured in a single instalment.
Hospital Cash Benefit means the insured person receives a pre-determined cash amount for each day of hospitalisation. A potential policyholder can purchase hospital daily cash insurance as an additional rider with their stand-alone health insurance policy. Some plans offer twice the fixed cash amount in case the insured person is admitted to an Intensive Care Unit (ICU).
Hospice refers to a special kind of care for patients nearing the end of their life. Under hospice care, healthcare professionals attempt to reduce the pain and symptoms of terminal diseases with the objective of improving the patient's quality of life and ensuring their comfort. Hospice care may also include attending to the patient's emotional and spiritual needs. Some health insurance providers provide hospice care as an additional rider.
A Health Insurance Calculator is a freely available online tool that enables prospective and existing customers to estimate the cost of their health insurance premiums. The health insurance premium calculator is available on insurance companies' websites. Interested customers must input their age, gender, family information, required sum insured amount, and contact details in the various tabs of the calculator to compute their estimated premium and receive an expense quote from the insurer.
Injury refers to any accidental physical bodily harm directly caused due to external, visible, or violent means. For a policyholder to file a health insurance claim for an injury, the injury should be evident, and a medical practitioner should verify and certify the injury as accidental. Policyholders can, however, file insurance claims for injuries like cuts, bruises, abrasions, etc., resulting from an illness or a disease.
An illness is a sickness, disease, or pathological condition that disrupts normal physical functions of the body. In health insurance, an illness is defined as a condition that occurs during the policy period. The policyholder can seek medical treatment, while the insurer bears the costs up to the sum insured. An illness can either be an acute condition or a chronic ailment. Acute conditions respond quickly to treatments, whereas chronic diseases need long-term monitoring and control.
In-patient care or in-patient treatment refers to the treatment covered under a health policy wherein a policyholder is obligated to stay hospitalised for at least 24 hours to file an insurance claim. Insurers generally list the various in-patient treatment courses covered under a health insurance plan in the policy agreement document.
Intensive care unit is a special section, ward, or wing of a hospital where patients receive specialised treatment for critical conditions. The level of care and supervision provided in the ICU is relatively more sophisticated and intensive than in regular hospital units.
ICU charges apply for the use of the Intensive Care Unit room. The rooms under this category involve advanced equipment to monitor and care for a patient's condition. The costs to place a patient in the ICU are relatively higher than those associated with standard hospital rooms. The insurance company reimburses the ICU room cost up to the room rent limit applicable in the policy.
IRDAI is short for the Insurance Regulatory and Development Authority of India. It is the national governing body that formulates the rules and regulations concerning insurance in India while regulating and promoting various insurance companies, their agents, and insurance brokers. The IRDAI plays a prominent role in protecting the rights and interests of insurance buyers within the country and supervises the orderly growth of the insurance industry.
An insurer is another term used to refer to an insurance company or an insurance provider. An insurer is an entity that offers insurance plans and covers the cost of medical expenses when a policyholder files a claim. The insurer provides coverage to the insured up to a specific sum insured and charges a premium from the policyholder for the coverage offered.
Insured refers to an individual/group named as a beneficiary of health insurance coverage under a health insurance policy schedule. These individuals or entities pay an annual premium to receive medical coverage if/when they need hospitalisation. The insured individuals are obligated to follow due process while filing or raising an insurance claim, which could be a cashless or reimbursement claim.
Individual health insurance is a type of health insurance plan that covers a single individual registered as the policyholder. Such an individual becomes the sole beneficiary of an insurance plan, which they cannot transfer to anyone else. Policyholders may customise their individual health insurance policies and extend their coverage with the help of various additional riders.
In general insurance policies, including health insurance plans, Lapse means the termination of an existing policy and the coverage offered under it. Insurers typically provide policyholders a 15-30 day grace period following their policy renewal/expiration date. If policyholders still do not renew their policy, it lapses, and the insurer is no longer liable to provide coverage. The insurer rejects all claims filed after a policy lapse.
Liabilities in health insurance refer to the expenses policyholders and insurance providers are contractually obligated to bear per the policy terms. Insurers' liabilities include the medical expenses up to the sum insured and per the insurance policy's established limits for variables (e.g. room rent, surgeon fees, etc.). Conversely, policyholders' liabilities include out-of-pocket expenses like deductibles, co-payments, and costs exceeding the sums insured and established variables limits.
Loss of independent existence is an individual's inability to perform everyday activities like bathing, dressing, eating, moving, etc., following a medical diagnosis or trauma lasting for at least six months. Such individuals may take time to recover and require life-long mechanical aids and devices. They may be eligible for expenses associated with loss of independent existence, such as hiring help, home nursing, daily cash benefits etc., based on their insurance plans.
Medical Treatment refers to the management and care a patient receives in order to combat a sickness, an illness or a disorder. Medical treatments may include hospitalisation and surgical procedures, day-care treatments completed within a few hours of admission or prescribing medication, physical therapy, and other healthcare services, to improve and restore bodily functions.
Medical Advice is the action plan a doctor or healthcare practitioner formulates after analysing a patient's medical condition. Based on the patient's condition, a medical practitioner may prescribe medications. The practitioner may also issue a follow-up prescription and recommend further tests, screenings, X-rays, and treatment plans if the issue at hand remains unresolved.
Medical Expenses entail the costs incurred by a health insurance policyholder towards their medical treatment based on the recommendation or prescription of a medical practitioner. Insurance providers typically cover or reimburse policyholders for various medical expenses in the event that the latter needs hospitalisation against an illness covered under health insurance. Common medical expenses covered by insurance providers include diagnostic tests, doctor's fees, hospital room rent, etc.
Costs related to pregnancy and childbirth are known as Maternity Expenses. In health insurance plans, maternity expenses are typically covered under an additional maternity cover rider that policyholders can purchase with their standalone health insurance plan. This cover allows policyholders to get coverage for normal and caesarean-section deliveries, pre-and post-natal expenses, delivery-related complications, lawful termination of pregnancy, etc.
A Medical Practitioner is a physician, doctor, or clinical specialist who holds a valid registration to practice medicine. The Medical Council of India or any Indian state should permit such an individual to practice medicine in its jurisdiction. Medical practitioners are obligated to provide patients with the necessary healthcare facilities and to act within the jurisdiction and scope of their medical license.
Medically Necessary Treatments are the healthcare services prescribed by a medical practitioner, which are necessary to diagnose and treat symptoms, illnesses, and injuries suffered by an insured party. Such treatments must conform to the professional standards accepted in the Indian medical community to pass medical insurance claims. Medically necessary treatments must also not exceed the scope, duration, and intensity of care required for treating health conditions.
Medical History indicates a potential policyholder's personal and family health records based on factors like age, profession, lifestyle choices, past surgical treatments, allergies, etc. Insurers use this information to understand the health risks and decide the health insurance premium. Individuals historically diagnosed with severe medical conditions or with a family history of medical conditions are usually charged higher premiums to mitigate the insurer's risk.
Mental Illness is defined as a disorder that affects an individual's thinking, perception, mood, and behaviour. Such a condition impairs judgement and compromises the ability to meet life's ordinary demands. Depression, anxiety disorders, schizophrenia, and dementia, are common examples of mental illnesses. Health insurance policyholders can get coverage for mental health treatment under their standalone health insurance policies, per IRDAI guidelines.
Insurance Providers typically categorise and list illnesses as minor and major/critical in the policy document. If diagnosed with a major illness, a health insurance policyholder becomes eligible for a Major Illness Benefit. Under this benefit, the insurer pays 100% or the maximum sum insured amount, whichever is lower. Policyholders must ride out the waiting period to be eligible for this benefit that helps pay for the treatment of illnesses like cancer, heart ailments, head trauma, etc.
Health insurance providers allow their existing policyholders to shift or migrate their current insurance plan to another product offered by them. Policyholders looking to migrate their policies must apply for Migration at least 30 days prior to their policy renewal date. Policyholders who utilise this option, who may have accrued benefits like no-claims bonus, ridden out the waiting period, and obtained continuous coverage without any lapse, can also migrate their amassed benefits to their new policy.
A Mediclaim Insurance Calculator is an automated online tool that enables potential and existing health insurance policyholders to estimate the cost of their insurance premiums. Insurance buyers must input details like their age, gender, type of coverage needed, etc., in the various tabs of the calculator. The calculator factors in these details to compute the estimated premium cost.
Material Facts represent the relevant, necessary facts an insurance company seeks in its proposal form and other associated documents. These facts enable insurance providers to determine whether or not to offer coverage to a potential insurance buyer. Material facts also help insurers ascertain the underlying risks of providing insurance coverage and making an informed decision in the process.
Health insurance providers ascertain several material facts about potential policyholders before offering them medical insurance coverage. One such fact is Medical History which indicates a potential policyholder's family medical history, past surgical history, long-term medication prescribed by doctors, social history, allergies, etc. Medical history enables insurers to understand a potential policyholder's health risks and decide the health insurance premium.
No Claims Bonus or NCB is a monetary benefit insurance companies provide to policyholders for not filing an insurance claim during a policy period. The reward is either a discount on the premium amount or an enhanced sum insured, depending on the type of general insurance policy held by the insured party. The bonus comes into effect at the time of policy renewal. Policyholders can get a maximum discount of 50% on the premiums, or an additional 50% of the sum insured, for every claim-free year, up to 5 consecutive claim-free years.
Network providers, also known as network hospitals, are healthcare facilities partnering with or enlisted by medical insurance providers. The partnership between network providers and insurance companies allows policyholders to seek cashless treatment at a network hospital/facility. Seeking treatment at a network provider's facility saves policyholders the trouble of paying cash upfront and filing reimbursement claims.
Non-network providers are those hospitals, healthcare facilities, day-care centres, and clinics which is not part of the insurance company's network. Non-network providers do not offer the cashless claims facility. Policyholders seeking treatment at non-network health facilities must pay their bills upfront and file for reimbursement of expenses by submitting all the relevant documents.
A new-born baby, in terms of an insurance policy, is a baby born within the tenure of an existing health insurance policy, and who is under the age of 90 days. Individual health plans do not cover new-born babies. However, policyholders can include their infants in a family health insurance plan. Under the policy, the baby gets its share in the sum insured like other family members.
Notification of claims is the process of informing an insurance provider or a third-party administrator (agent, broker) about a policyholder's intention to file an insurance claim. Policyholders can notify their insurance providers about their intent to file a claim through communication modes recognised by the insurer and mentioned in the policy document. They must notify the insurer within 24 hours of emergency hospitalisation and 48 hours before hospitalisation for planned treatments.
A nominee is a person nominated as the recipient of the health insurance benefits in the event of the policyholder's death. The insured can change the nominee during the course of the policy period by means of a non-financial endorsement. In case of the nominee's death, and in the event that a nominee is not listed, the insured person's legal heirs receive the sum insured amount.
Certain items charged during the hospitalisation and treatment process are excluded from the scope of coverage. Such expenses are collectively known as non-medical expenses, which insurers mention in the medical insurance policy schedule. Common examples of non-medical expenses include attendant and laundry charges, thermometers provided by hospitals, nebulisers, belts, braces, etc.
No Claims Bonus Protector is a facility that protects the percentage of cumulative or enhanced cumulative no-claim bonus accumulated by a policyholder during a policy period. The conditions of protection involve a claim amount not exceeding a fixed sum, as mentioned in the policy document at the time of policy renewal. To enjoy the no-claims bonus protector benefits, policyholders must avail of this option at the time of the policy's inception, i.e., when they first purchase the policy.
A nuclear attack refers to the use of any nuclear weapons or devices that emit radioactivity and cause illnesses, disablement, or death of an insurance policyholder. Medical conditions caused due to nuclear attacks are typically excluded from coverage under a health insurance policy.
A non-financial endorsement is a written endorsement policyholders can make to request insurance providers to modify certain aspects of their insurance plans. Such an endorsement does not impact the financial aspect of an insurance policy, i.e. the insurance premiums. Common examples of non-financial endorsements include minor rectifications or corrections to an insured person's name, spelling, gender, date of birth, correspondence address, nominee details etc.
An optional cover is a separate, usually minor package that enhances a standard insurance policy's coverage while offering financial protection to policyholders against certain specific and high-cost medical treatments. The insurance company generally charges a slightly higher premium for the add-on rider. Examples of add-on covers include, maternity cover, critical illness cover, hospital cash benefits, etc.
The Out-Patient Department (OPD) is an individual healthcare facility (e.g. a clinic) or a hospital department that offers consultation services and diagnoses and treats patients based on a medical practitioner's advice. OPD deals with medical care that does not require hospitalisation. Insurance providers typically cover OPD expenses like medical tests, routine check-ups, physiotherapy, dental treatments, doctor's fees, etc., based on a health insurance policy's terms.
A medical treatment plan which does not require a patient to be hospitalised is known as an out-patient department or OPD Treatment plan. OPD treatments typically include consultations and minor procedures completed at OPD facilities, following which the patient can complete the remaining treatment course at home. Insurance providers usually cover the costs of various OPD Treatments mentioned in the policy documents.
Out-Of-Pocket Expenses are those costs that an insurance provider is not liable to cover per the policy terms. The policyholder must bear such costs on their own. In health insurance, deductibles and co-payments are examples of typical out-of-pocket expenses. Any amount exceeding the sum insured or the established expense limit per variable (e.g. room rent) also falls under out-of-pocket expenses.
Organ Donor Expenses entail the costs associated with hospitalisation for an organ donor wherein the organ recipient is an insured person. Per IRDAI guidelines, an organ donor must comply with the Transplantation of Human Organs (Amendment) Bill, 2011, and the other relevant laws to qualify for expense coverage. Medical insurance plans may not cover pre and post-hospitalisation expenses for organ donors.
Premium is the amount an insurance buyer must pay to an insurance provider in order to avail of health insurance coverage. Insurance companies typically charge premiums on an annual basis. Policyholders must pay premiums every year on or before the policy expiration date to renew their health insurance plan and receive uninterrupted insurance benefits.
Pre-Hospitalisation Medical Expenses are those that a patient typically bears during the illness diagnosis stage. During this stage, patients may need to consult doctors and undergo screening tests. Based on their condition, the doctor may recommend hospitalisation or surgery. Thus, the costs incurred before a patient is hospitalised are known as pre-hospitalisation medical expenses. Insurance companies usually cover expenses incurred up to 30 days before hospitalisation.
Post Hospitalisation Medical Expenses are those a patient must incur after being discharged from the hospital. Patients typically have to incur these expenses based on a medical practitioner's recommendations and to prevent the relapse or recurrence of a medical condition. Examples of post-hospitalisation medical expenses include medical consultations, follow-up treatments, medication, diagnostic tests, etc. Insurers generally cover costs incurred over 45-90 days after hospitalisation.
Payment of a Claim is the sum an insurance company pays a policyholder if the latter files a rightful insurance claim. It is the benefit an insurer offers to a policyholder in exchange of the annual insurance premiums collected from the policyholder. The claim amount enables the policyholder to bear the costs associated with medical treatment per the policy terms. Payments of claim may be applicable for both cashless and reimbursement claims.
Portability refers to the process of transferring a health policy from one insurance company to another. Portability allows policyholders to carry forward the accumulated benefits of their health insurance plan, such as their no-claim bonus, waiting period, etc., to their new insurance provider. Policyholders can use this option at least 45 days before but not earlier than 60 days from the policy renewal date.
Preventive Health Check-up refers to medical examinations policyholders can undergo annually to detect any changes in their existing medical condition. The check-up enables them to diagnose illnesses in the nascent stage and take appropriate medical action. Under section 80D of the IT Act, policyholders can avail of an annual tax deduction of ?5000 on preventive health check-up costs. However, the overall deduction depends on the maximum tax exemption limit.
Pre-Existing Diseases are any illnesses prevalent in an individual prior to them purchasing a health insurance policy. The terms and conditions of coverage surrounding pre-existing disease insurance differ from a standalone health insurance plan. Insurers typically mention the pre-existing diseases for which they offer coverage. Policyholders can file claims for pre-existing diseases are riding out a waiting period of 24-48 months.
The Policy Period, also known as Period of Insurance, is the tenure during which a health insurance provider offers coverage for a valid and existing health insurance policy. It is the duration between the policy's commencement date and expiration date. A typical health insurance policy comes with a policy period or tenure of 1 year.
A Policy is a legal contract between an insurance company and an insurance buyer. It comprises all the necessary information a policyholder needs to know regarding their chosen insurance policy. The vital information mentioned in a policy document includes the detailed terms and conditions of insurance coverage, the inclusions and exclusions, information about insured parties' benefits, the sum insured amount, the claim process, etc.
The Policy Schedule is an essential component of an insurance policy. It comprises information pertaining to the insurance buyer and is different for every policyholder. The specific details included in a policy schedule include the name and contact details of the insured parties (which could be multiple persons in case of family floater plans), the sum insured amount, the policy period, benefits covered, etc.
A Policyholder is a person who is listed as the primary owner and beneficiary of an insurance policy. This person is eligible to make any changes or modifications to the policy. Policyholders can typically modify their existing policies at the time of renewal and are usually responsible for paying the insurance premiums for themselves and their dependents.
Personal Accident Cover is a fixed benefit plan under which policyholders receive a one-time payment of a predetermined sum. This pay-out is made to the policyholder in the event of an accident leading to their disability. If the accident leads to the policyholder's death, the insurer pays the fixed amount to their nominees. Personal accident cover does not cover the medical costs incurred by policyholders. It is a lump sum payment made only in the event of accidents impacting a policyholder's quality of life.
A qualified nurse is an individual holding a valid registration certificate issued by the Nursing Council of India or their respective state's Nursing Council. Hospitals, day-care centres and other registered healthcare facilities are obligated to employ qualified nurses from these councils as part of their nursing staff.
Renewal is the act of extending the validity period of an existing general insurance policy. Renewal allows policyholders to continue enjoying the benefits and coverage offered by their insurance provider and prevents their policy from expiring or lapsing. Policyholders must pay an annual premium to renew their policy and abide by renewal-specific terms, including paying the premium before the policy expiration date or the grace period. Failure to renew the policy on time can result in the insurer terminating the policy.
A Recovery Benefit is a lump sum amount that an insurance company provides to a policyholder for medically necessary hospitalisation. Policyholders can avail of the recovery benefit in the event that their hospitalisation duration exceeds ten consecutive days. Insurers offer this benefit over and above the sum insured amount, and the benefit does not reduce the applicable sum insured of a given policy. The recovery benefit amount differs from one insurance policy to another.
Insurance companies offer various perks to policyholders for renewing their general insurance plans on time. These perks are collectively called Renewal Benefits. Lucrative renewal benefits offered to policyholders upon renewing a health insurance policy include continuous and uninterrupted coverage, a no-claims bonus that enhances the sum insured, and suspended /reduced waiting periods, especially for critical illness and pre-existing disease policies with longer waiting periods.
A Reset/Restoration benefit allows policyholders to restore their sum insured upon exhausting it in a policy year. This benefit is offered as an add-on rider with medical insurance plans. The reset benefit is applicable on a partial (restoration after exhausting only a specific portion of the sum insured) and total (restoration after utilising the entire sum insured) exhaustion basis. This add-on rider is ideal for family health insurance policies generally covering several people under a single insured sum.
Road Ambulance Cover is an add-on rider offered by health insurance providers. It covers expenses in the event that a policyholder needs to call an ambulance to transport a patient to the hospital. Insurers cover the charges associated with transporting policyholders to the nearest hospital during an emergency, commuting from one hospital to another, and transferring patients from the hospital to their homes. Insurers usually set a limit or cap on the road ambulance cover amount.
Reasonable and Customary Charges are the charges levied by healthcare facilities for services provided and supplies used while treating an injury or illness. Insurance providers typically cover these "customary" charges so long as they meet the industry standards and are "reasonable". The charges should be consistent with the prevailing expenses in a given geographical area offering similar services, based on the nature of the injury or illness for which the policyholder is seeking treatment.
Reimbursement is a process wherein an insurance provider settles the cash claims submitted by policyholders. Policyholders typically file for reimbursement after seeking treatment in a non-network hospital. Policyholders must submit detailed, itemised bills for all expenses incurred, including costs of diagnostic tests, doctor's fees, hospitalisation charges, etc., to be eligible for reimbursement. The insurance company evaluates the claim and reimburses expenses up to the sum insured limit.
Insurance companies acknowledge complaints and concerns through a process called Redressal of Grievances. Policyholders can submit this complaints and requests by contacting their insurance company's toll-free number or sending an email ID. They may also contact the Integrated Grievance Management System of the IRDAI or visit the nearest Insurance Ombudsman office for grievance redressal.
The Sum Insured in health insurance is the insurance provider's maximum liability towards the policyholder's medical expenses for a policy year. If the medical expenses exceed the sum insured limit, the policyholder is liable to pay the excess costs from their pocket. Factors like age, lifestyle habits, and pre-existing health conditions influence the sum insured amount.
Surgery or Surgical Procedures are treatments conducted by licensed medical practitioners after assessing a patient's medical condition. Medical practitioners may recommend surgeries if/when prescription medicine does not relieve a patient of an illness. Surgeries help correct defects and deformities, treat injuries, relieve suffering and help prolong the insured's life. The medical practitioner may perform surgery at a hospital or a day-care centre.
Specific Exclusions are a set of notable exclusions in a health insurance policy wherein the insurance provider is not liable to honour claims. Specific exclusions comprise medical expenses due to war, rebellion, detainment, nuclear attacks, etc. Treatment undertaken outside India, pregnancy termination unless medically necessary, suicide attempts, and injuries sustained by policyholders due to their involvement in criminal activities are a few other specific exclusions.
Standard Exclusions are medical costs associated with treating diseases and ailments or post-surgery expenses for which the insurance provider is not liable to reimburse the costs. Typically, standard exclusions comprise diagnostic fees, home nursing, hospice care, cosmetic surgery, etc. Standard exclusions can differ across policies and insurance providers.
A Sum Insured Refill, also known as Sum Insured Restoration, is an additional rider that policyholders can purchase. Policyholders who opt for the sum insured refill rider can get their entire sum insured restored after utilising it. Policyholders can choose from partial and complete sum insured refills and enjoy this benefit once per policy year after filing an insurance claim within that policy year.
Sub Limit in health insurance is a fixed amount or percentage of the sum insured designated for specific medical expenses. For instance, a policy may state that the insurance provider is liable to pay 10% of the basic sum insured or Rs 50,000, whichever is lower, for treating mental health conditions. Similarly, the sub-limit for hospital room rent may be Rs 2,000 per day of hospitalisation.
When receiving treatment at a hospital, policyholders can choose to stay in general wards or private rooms. Patients intending to file an insurance claim and considering lodging in a Single Private Air-Conditioned Room must ensure that they seek admission in the most economical of all the single accommodations available in the hospital. Also, the room rent expense should be within the sub-limit determined under the insurance policy. This does not include suites or deluxe rooms.
In critical health insurance, the Survival Period is the duration a policyholder must survive after receiving a medical diagnosis for a critical illness. The survival period comes into effect after the policyholder rides out the waiting period and after 15 to 30 days of receiving the critical illness diagnosis. Policyholders who survive this period become eligible for the lumpsum amount of the sum insured, per policy terms.
Third party administrators or TPAs are companies and entities licensed by the Insurance Regulatory Development Authority of India (IRDAI) and authorised/engaged by insurance companies to conduct business on their behalf. TPAs collect premiums, process and settle cashless and reimbursement claims, and offer administrative services on behalf of the insurance provider.
A Top-Up Plan is an insurance rider that policyholders can purchase over and above their existing health insurance plan. Top-up plans typically increase the policyholder’s sum insured limit, enabling them to enhance their coverage substantially. Policyholders can opt for top-up and super top-up plans at the time of policy renewal only and can file multiple claims in a policy year by adding this rider.
Illnesses or diseases that do not have a permanent cure or those that can only treat certain but not all symptoms of an illness, despite extensive medical care are known as terminal illnesses. Terminal illnesses usually result in death or indefinite unconsciousness (coma) from which a patient is unlikely to recover. Advanced-stage cancer, heart diseases, neurological diseases, etc., are examples of terminal illnesses.
Time deductible is the duration the policyholder has to wait before receiving health insurance benefits. Typically, time deductibles include a specific number of hours and have no impact on the sum insured.
Treatment is defined as a process under which medical professionals employ various procedures to nurse a patient back to good health. Under health insurance plans, notable forms of treatments include medication, surgery, physical therapies, etc. Health insurance providers generally cover the treatment costs of various medical conditions, which they list in detail in their policy documents.
Territorial limit is a term indigenous to most health insurance plans. Under the territorial limit clause, the insurance provider only pays for the medical expenses associated with treatments within the territorial border of the country in which the policy is issued. For insurance policies in India, insured parties can file claims only for treatments sought within the territorial limit of India. Insurance providers can reject claims for treatment sought overseas.
Unproven Treatments, also known as experimental treatments, are those treatment forms not backed by significant medical proof indicating or supporting their effectiveness. While these treatments may be based on established and recognised medical practices in India, they may still be in the experimental stages (e.g. clinical trials, experimental drug therapy), hence rendered unproven. Due to their unproven nature, policyholders seeking such treatments do not qualify for medical insurance.
In a medical insurance plan, the waiting period is the length of time a policyholder must wait to avail of insurance benefits as specified in the policy. The insurance provider is not obligated to accept claims during the waiting period. A basic health insurance plan usually has 30 days initial waiting period which is not applicable in case of accidents . Additionally, the waiting period for pre-existing diseases and critical illness plans can range from two to four years.
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