How Indian health insurance policies are built: coverage terms, limits, waiting periods, claims and portability. This topic has 26 entries.
Health insuranceIndemnity health insuranceIndemnity health insurance pays the actual medical expenses an insured person incurs on covered treatment, up to the sum insured and subject to policy limits, rather than a fixed amount.Health insuranceFamily floater health insuranceA family floater is a health insurance policy in which one shared sum insured covers several family members, so any one member, or several together, can use the full cover in a policy year.Health insuranceGroup health insuranceGroup health insurance is a single health policy issued to a master policyholder, usually an employer, that covers all members of a defined group, often with family members, under common terms.Health insuranceTop up and super top up health insuranceTop up and super top up health insurance are indemnity policies that pay hospital bills only above a set threshold, the deductible, giving high cover for less than a bigger base policy.Health insuranceCritical illness insuranceCritical illness insurance is a benefit based health cover that pays a fixed lump sum when the insured is diagnosed with a listed serious illness, such as a specified cancer, whatever the bills.Health insuranceDeductibleA deductible in health insurance is a fixed amount of covered expenses the policyholder bears before the insurer pays, applied per claim, per year or both, and subtracted from larger claims.Health insuranceCo-paymentCo-payment is a cost-sharing clause in a health policy under which the policyholder pays a fixed percentage of every admissible claim, and the insurer pays the rest, up to the sum insured.Health insuranceSub-limits and room rent limitsSub-limits are caps inside a health policy on what the insurer pays for a specific item, illness or procedure, such as room rent per day or cataract surgery, even if sum insured remains.Health insuranceWaiting period in health insuranceA waiting period is the time after a health policy starts when some claims are not paid: an initial period, specific periods for listed conditions, and one for pre-existing diseases.Health insurancePre-existing diseaseA pre-existing disease (PED) is a condition diagnosed, or for which medical advice or treatment was recommended or received, within 36 months before a health policy starts.Health insuranceMoratorium period in health insuranceThe moratorium period is 60 continuous months of health cover after which the insurer cannot contest the policy or a claim for non-disclosure or misrepresentation, except for established fraud.Health insuranceCashless claimA cashless claim is a health insurance claim in which the insurer or its TPA pays the hospital directly for covered treatment, so the patient pays only non-covered items and policy deductions.Health insuranceReimbursement claimA reimbursement claim is a health insurance claim in which the policyholder pays the hospital first and the insurer later repays the admissible amount, due within 15 days under IRDAI rules.Health insuranceTPA (third party administrator)TPA (third party administrator) is the term for an IRDAI-registered company that services health insurance claims for insurers, handling cashless approvals and claim processing.Health insuranceNetwork hospitalNetwork hospital means a hospital or healthcare provider with a tie-up with a health insurer or its TPA to treat that insurer's policyholders on a cashless basis at agreed rates.Health insuranceHealth insurance portability and migrationHealth insurance portability lets a policyholder move an indemnity health policy to another insurer at renewal, and migration to another plan of the same insurer, keeping waiting period credits.Health insuranceNo claim bonusNo claim bonus in health insurance is a reward for a claim-free policy year, given at renewal either as a cumulative increase in the sum insured or as a discount on the renewal premium.Health insuranceRestoration benefitRestoration benefit is a health insurance feature that refills the sum insured, fully or partly, after claims use it up within a policy year, so that later hospitalisations stay covered.Health insuranceDay care treatmentDay care treatment is a medical or surgical procedure done in a hospital or day care centre in less than 24 hours because of advances in technology, which health policies cover like an inpatient stay.Health insuranceDomiciliary hospitalisationDomiciliary hospitalisation is cover for treatment at home, on medical advice, for an illness that would normally need admission, when the patient cannot be moved or no bed is free.Health insurancePre and post hospitalisation expensesPre and post hospitalisation expenses are medical costs for the same condition in a fixed number of days before admission and after discharge, which a health policy pays alongside the hospital claim.Health insuranceAYUSH treatment coverAYUSH treatment cover is health insurance for hospital treatment under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, which IRDAI requires insurers to treat at par with other systems.Health insuranceArogya SanjeevaniArogya Sanjeevani is IRDAI's standard individual health insurance policy, sold by general and health insurers under one name with uniform cover, so buyers compare only premium and service.Health insuranceSenior citizen health insuranceSenior citizen health insurance is cover for people aged 60 and above, now shaped by IRDAI rules on open entry ages, capped premium increases and a separate claims channel.Health insuranceMaternity coverMaternity cover is a health insurance benefit that pays for childbirth and related care, usually after a waiting period in retail plans, within set limits for normal and caesarean delivery.Health insuranceOPD coverOPD cover is health insurance for outpatient care that does not need hospital admission, such as doctor consultations, diagnostic tests, medicines and dental or vision care, within a set annual limit.
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