FAQs about health insurance.

  Q1. What is health insurance ? Is it same as a mediclaim policy ?  
      Health Insurance is an insurance policy which covers you and your family against any medical contingency. It 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 or reimburses the expenses associated with illnesses and injuries. Health insurance and mediclaim policy are same and the terms are used interchangeably.   
  Q2. Is Health Insurance the same as Life Insurance ?  
        No. Life Insurance protects your family (or dependents) from financial loss that may arise in the event of your untimely death/or if something happens to you. The payout is made only post the death of the person insured or at the maturity of the policy. Health Insurance protects you against ill health/diseases by covering the expenses you might incur (for treatment, diagnosis etc.) in case you are affected by disease or injury. There is no maturity benefit in health insurance.   
  Q3. What are covered covered under mediclaim policy ?  
        Most of the mediclaim policies cover charges towards
  • Normal Room, ICU room,, Board and Nursing expenses
  • Surgeon, Anesthetist, Medical Practitioner, Consultant and Specialist fees.
  • Cost of Anesthesia, Blood, Oxygen, Operation Theatre, Surgical Appliances, Medicines & Drugs, Diagnostic Materials and X-ray, Dialysis, Chemotherapy, Radiotherapy, Pacemaker, Artificial Limbs, Organs and similar expenses.
  • Ambulance charges.
  • Pre-Hospitalization expenses for 30 days.
  • Post Hospitalization expenses for 60 / 90 days each.
  • Cost of Health Check-up is given free once in a block of 4 claim free policy years.
  Q4. Does Mediclaim cover any expenses besides hospitalization costs ?   
        Yes. Mediclaim covers pre-hospitalization (30 days) and post-hospitalization (generally upto 60 days) expenses also if they are connected with the sickness / accident for which the hospitalization has taken place .  
  Q5. What is considered as "domiciliary hospitalization" under Mediclaim? Is it covered ?  
       It is that condition of the patient in which he cannot be moved to the hospital or if there is no bed available in any of the hospitals, then the treatment is taken at home. Under these circumstances treatment given at home is called Domiciliary hospitalization and the expenses are reimbursable.   
  Q6. What are the general exclusions in a health insurance policy ?  
      Every health insurance policy has a set of exclusions.
  • Any claim in the first 30 days (other than due to accident) is excluded.
  • AIDS, sexually transmitted diseases, cosmetic surgery and dental surgery (unless required due to an accident) are permanently excluded.
  •  Naturopathy and Homeopathy treatments generally excluded
  • Infertility related expenses
  • Temporary exclusions like hernia, cataract & sinusitis which are not covered in the first year of the policy but may covered in subsequent years.
  •  Surgery related to Joint replacement (unless due to an accident )
Conditions arising from diseases existing before the purchase of the policy are not covered. These “preexisting” diseases are covered usually after 4 years of the policy being in force depending on the policy terms & conditions  
  Q7. Are Maternity/Pregnancy related expenses covered under Health Insurance plans?  Back to top  
        No. Life Insurance protects your family (or dependents) from financial loss that may arise in the event of your untimely death/or if something happens to you. The payout is made only post the death of the person insured or at the maturity of the policy. Health Insurance protects you against ill health/diseases by covering the expenses you might incur (for treatment, diagnosis etc.) in case you are affected by disease or injury. There is no maturity benefit in health insurance.   
  Q8. Are dental treatment covered in your insurance ?  
  As mentioned above, any dental treatment or surgery of a corrective, cosmetic or aesthetic nature, unless it requires hospitalisation and is carried out under general anesthesia and is necessitated by illness or Accidental Bodily injury is not covered in the insurance.  
  Q9. Are cosmetic treatments or medical attention for cosmetic purposes covered ?  
        No. Cosmetic treatments (including any complications arising out of or howsoever attributable to any cosmetic treatments or the placement of an existing breast implant), aesthetic treatments, experimental, investigational or unproven procedures or treatments, devices and pharmacological regimens of any description is not covered. The treatment of obesity (including morbid obesity) and any other weight control programs, services, or supplies is not covered. Neither is costs incurred in connection with the provision or fitting of contact lenses is covered.   
  Q10. Will Mediclaim reimburse my expenses related to the disease which I am already suffering before the inception of the plan ?  
       Insurance company will not cover any illness/ailment which already existed at the time of first obtaining the insurance cover. However, some companies cover such conditions after, two or four continuous renewals; they start covering the pre-existing illness. There may not be such restrictions in a group policy.  
  Q11. Are naturopathy and homeopathy treatments covered under a health policy ? Back to top  
       The coverage is available only for allopathic treatments in recognized hospitals and nursing homes.   
  Q12. Why is it important to disclose health details when I buy a policy?   
        One must disclose every detail about any disease or illness one had or any treatment one is undergoing while taking the policy. An insurance contract works on the principal of “utmost good faith”, so not disclosing your health details will not be correct. Furthermore, non-disclosure can also lead to rejection of your claim.  
  Q13. Can I apply for a Health insurance policy when I am already diagnosed with some disease or ailment ?  
        Yes, you can apply for a Health Insurance policy. But the policy will be issued excluding the diagnosed disease and other diseases pre-existing at the time of inception of the cover.    
  14. Is a medical checkup necessary before buying a policy ?  
        A medical checkup is generally not required for customers unless they are above 45 years of age. Medical checkups are usually not needed for renewal of policies.  
  Q15. What is critical illness benefit and how is it different from health insurance policy ?  
        A Health Insurance policy reimburses medical expenses .A critical illness insurance is a benefit policy. Critical illness is the first time diagnosis of any one or more of the illness such as cancer, first heart attack, kidney failure, paralysis, stroke etc. When critical illness is diagnosed, the insurance company pays the policyholder a lump sum amount. This lump sum is paid provided the insured survives a specific period (say 45 days) after the occurrence of the event. Whether the client spends the amount received on the medical treatment or not depends on the client's own discretion. Once paid the critical illness cover ceases to exist. Sometime Critical illness cover is given as an add on cover to the health insurance policy.   
  Q16. How is health insurance different from personal accident insurance ?  
        In a Personal Accident policy a predefined lump sum is payable on death or on disability due to an accident. Incase of health insurance policy the amount paid is limited to the actual expenses incurred. Also under a personal accident policy the medical reimbursement benefit is generally limited to 40% of the actual expenses. Death benefit is not available in health insurance whereas it is available under personal accident policy. Personal accident policy may pay loss of salary due to an accident whereas no such benefit is available in a health policy.   
  Q17.  What is a family floater health insurance plan ?  
       A family is defined as comprising of the insured, spouse and children. Generally parents, in-laws and siblings are excluded from the beneficiary list. Under a family floater plan the sum assured floats among all members of the family (generally without sub limits). For example if A is the insured, B, C and D are members of the family and sum assured is Rupees five lacs,  then any of the members can claim up to rupees five lacs subject to the overall claim limit of the family of rupees five lacs.  
  Q18. My family members are residing in a place different from the place where I am residing ? Can I cover all of us in one policy ?  
        Yes, you can cover the entire family under one policy. Your health insurance policy is in force across India. You must check whether there are any network hospital near to your as well as your family's place of residence. You must check if your insurer has a network hospital close to you or where the rest of your family resides. Network Hospitals are the hospitals that have tied up with the TPA (Third Party Administrator) for cashless settlement for expenses incurred there. If there are no network hospitals at the place of your residence, you could opt for reimbursement mode of settlement.   
  Q19. Can I buy more that one Health Insurance policy ?  
        Yes. one can have more than one Health Insurance policy. In case of a claim, each company will pay ratable proportion of the loss. For example, a customer has Health Insurance from Insurer A for a coverage of Rs. 1 lakh and Health Insurance from Insurer B for a coverage of Rs. 1 lakh. In case of a claim of Rs. 1.5 lakh each policy will pay in the ratio of 50:50 up to the sum assured.   
  Q20. My employer provides me with health insurance coverage. Is it advisable to take another policy on my own?  
        It is strongly advised to have health insurance on your own as well because of reasons of continuity. Firstly, if you change your job, you might not necessarily get health insurance from your new employer. In any case you will be exposed to health costs in the transition period between jobs. Secondly, the track record that you have built in health insurance at your old employer will not transfer to the new company policy. Covering pre existing diseases might be a problem. In most policies pre-existing diseases are covered only from the 5th year onwards. Therefore it is advisable to take a private policy in addition to your company provided group health insurance policy.  
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  Q21. My employer has provided me with a health insurance policy of Rupees two lac sum assured. I also have a separate individual policy of rupees two lacs.  If the hospitalization expenses is rupees three lacs, can I use my personal mediclaim policy for the balance of rupees one lac ?  
        Yes, your personal health insurance policy can be used for the balance of rupees one lac. In order to use this, the insured needs to take a certificate from the TPA (of group mediclaim policy), that the limit has been exhausted and submit the same to the TPA (of individual mediclaim policy).  A broker should normally assist you in such situations.   
  Q22. Can I include my parents in the mediclaim policy ?  
        Parents are generally not included in the individual family floater mediclaim policy, but some policies like ‘Happy Family floater policy” of Oriental Insurance company limited allows the insured to include either parents or in-laws subject to underwriter’s approval. Group policies may include parents of the employees. One can buy senior citizens policy for persons aged above 60 years. It helps to contact your broker to know which the insurance companies offering products for elderly personnel.   
  Q23. What are the documents required for buying a health insurance?  
       No documents are required for purchasing health insurance. As of now, you do not even need any PAN Card or ID proof. Depending on the norms of the insurer and the TPA. You might need to furnish documents like ID proof at the time of submitting a claim.  
  Q24. What are the documents required for settlement of claim in case the insured is admitted to a non network hospital ?  
        It is important that the insured maintains all the original documents like doctors diagnosis, doctors recommendations for X-ray, blood tests etc, original discharge card, bills for which payment has been made, X-Ray plates along with x-ray reports, blood tests reports etc. These documents along with duly filled up claim and a copy of the health card form needs to be submitted to the TPA at the earliest. It is advisable that you inform the TPA at the time of the admission of the patient in the hospital. It is advisable to purchase a policy through a broker as he shall quickly assist the client claim settlement.   
  Q25. What do you mean by sum insured ?  
        Sum insured is the maximum extent to which the insurance company will reimburse you for the medical expenses incurred by you. Usually, mediclaim policies start with a low coverage amount of Rs 25,000 and go to a maximum of Rs 10,00,000.    
  Q26.Is it possible to change the sum insured during the term of the policy ?  
        Generally insurance companies accept the reduction in the sum insured during the term of the policy. In such a case the premium for the balance period on the sum assured reduced is refunded to the insured on short period rates. Increase in sum assured is generally not accepted during the policy period.  
  Q27. Who is a Third Party Administrator ?  
        A Third Party Administrator (commonly referred to as TPA) is an IRDA (Insurance Regulatory and Development Authority) approved specialized health care service provider. A TPA provides the insurance company with a variety of services like networking with hospitals, arranging for cashless hospitalization as well as claims processing & timely settlement.   
  Q28. What is meant by Cashless Hospitalization ?  
        In the event of hospitalization, the patient or their family will have a bill to pay the hospital. Under Cashless Hospitalization the patient does not settle the hospitalization expenses at the time of discharge from hospital. The settlement is done directly by the Third-Party Administrator (TPA) on behalf of the health insurer. This is for your convenience.  It is important that the insured talks to the hospital authorities and get the necessary authorization for cashless settlement from the TPA. However, prior approval is required from the TPA before the patient is admitted into the hospital. In case of emergency hospitalization, approval can be obtained post-admission. Please note that this facility is available only at the network hospitals of the TPA.   
  Q. 29. What is a Health Card ?  
        A Health Card is that card which comes along with the policy which would entitle you to get cashless claim at any of the company’s network hospitals. One needs to carry the health card to the hospital for availing the cashless facility. In appearance the health card resembles a debit card issued by a bank.   
  Q30. What are the minimum and maximum policy durations? Is Health Insurance the same as Life Insurance ?  
        Health insurance policies are general insurance policies usually issued for a period of one year only. However, some companies also issue a two or three year policy. At the end of your insurance period you must renew your policy.  
  Q31. What is the maximum number of claims allowed over a year ?  Back to top  
        Any number of claims is allowed during the policy period. However the sum insured is the maximum limit under the policy.   
  Q32. What happens to the policy coverage after a claim is filed ?  
        After a claim is filed and settled, the policy coverage is reduced by the amount that has been paid out on settlement. 
For Example: In January you start a policy with a coverage of Rs 5 Lakh for the year. In April, you make a claim of Rs 2 lakh. The coverage available to you for the May to December will be the balance of Rs.3 lakh. As mentioned above the coverage under critical illness may cease to exist once the claim is made though the coverage under the mediclaim may continue. 
  Q33. What happens when I cancel the policy ?  
        If you cancel the policy, your cover will cease to exist from the date of cancellation of policy.  Additionally, your premium would be refunded to you on short period cancellation rates. You will find these in the policy terms and conditions in the policy document.   
  Q34. Can I avail this policy if I am not an Indian National but living in India ?  
        Yes, foreigners living in India can be covered under a health insurance policy. However, the coverage would be restricted to India.   
  Q35. Can I use my mediclaim policy for availing medical treatment in foreign country, if I fall sick during my trip abroad ?  
        No. Mediclaim policy issued in India is valid for treatment within the country. One needs to take an overseas travel policy with medical cover for treatment in foreign country, if one fall sick while travelling abroad.   
  Q36. What are the factors which determine the premium payable for health insurance ?  
       Under health Insurance, the age and the amount of cover are the factors that decide the premium. Usually, younger people are considered more healthy and thus pay lower annual premium. Older, people pay a higher health insurance premium as their risk of health problems or illness is higher.    
  Q37. Who will receive the claim amount under health insurance if the policyholder dies during the time of treatment ?  
        In cashless mediclaim settlement, it is settled directly with the network hospital. In cases where this is no cashless settlement, the claim amount is paid to the nominee of the policyholder. In case there is no nominee made under the policy, then 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 next legal heirs of the deceased.   
  Q38. What are the tax benefit that one can avail of while purchasing Health Insurance ?  
        Tax benefit is available under Section 80D of the income tax act 1961. Every tax payer can avail an annual deduction of Rs. 15,000 from taxable income for payment of Health Insurance premium for self and dependants. For senior citizens, this deduction is Rs. 20,000. Please note that you will have to show the proof for payment of premium.  
  Q39.What is a deductible ?  
        It is a specific  amount that an individual must pay (or "satisfy") before reimbursement for expenses begins. The higher the deductible, the lower the cost of the health insurance plan. For example if the deductible is Rs. 1000/- and the claim amount is Rs. 11,000/- then the insurance company will pay Rs. 10,000/- to the insured.  
  Q40. What is co insurance ?  
       Coinsurance is a feature found in most group health insurance plans. It sets forth the percentage of covered expenses that the employees and the health insurance plan will pay. The most common coinsurance level is one in which the employee pays say 20 percent of the expenses and the insurer pays 80 percent. This is called 80 percent coinsurance.  
  Q41.  What is an Excess ?  Back to top  
        Excess is the amount up to which no amount will be payable by the insurance company. Amount over and above the excess is paid by the insurance company. For example, if the excess is Rs. 750/- than any claim up to Rs. 750 is not payable. If the claim is amount is Rs. 5000/-then the amount payable to the insured is Rs. 4250/-.   
  Q42. Do I get a No Claim Bonus under my health insurance if I do not make a claim ?  
        Yes, some plans offer a discount in premium. Others offer an increase in your benefit amount for every claim- free year.  
  Q43. Why I should buy a policy from a broker ?  
        A broker is an IRDA approved entity who works for a client unlike an agent who works for an insurance company. Broker is independent in a respect that he can sell the products of any insurance company which he feels is fit for the client. Hence one can expect an unbiased view about a product from an insurance broker. As the broker deals with all the insurance companies he has better market knowledge about the products available in the market. Also IRDA prescribes stringent guidelines in terms of capital, infrastructure, and qualification of personnel etc before granting license to a broker. Hence one can expect better service levels from a broker.The above FAQs have been designed in the Indian context and may or may not be valid for insured residing in other countries.