Health Medical Insurance FAQ

All insurance company in India excludes coverage for pre-existing diseases for a defined tenure which is specified at the beginning of the policy. Most waiting periods for pre-existing medical conditions are in the region of 36/48 months after which they can be covered for such diseases and any treatments arising out of such conditions. One must be aware of the waiting periods and the sum insured for treatment due to pre-existing conditions.

The normal defined process is to get in touch with the Third Party Administrator (TPA) who is designated by the insurance company to manage claims and be the first point of call during a claim. The contact details of the TPA are available on the policy docket and the health card provided by insurance company while issuing the insurance policy. As a fall back, the insured can also reach out to the insurance company directly on their Toll Free Assistance numbers to inform them about the hospitalisation. The insured may also choose to quickly check the nearest network hospital and get admitted to the hospital first before informing the TPA / Insurance company. The insured should remember to keep the policy number handy while seeking support from the TPA/Insurance company to ensure quicker , timely and more efficient assistance.

Off course the insured can get admitted to a Non Network hospital in an emergency situation. But the insured must be awarethat at a Non Network hospital, cashless treatment is not available, which means that treatment will be on a reimbursement basis. Hence the insured/family must settle the medical bills with the hospital upfront and then get them reimbursed from your insurer and so one must retain all bill/receipts received from the hospital and submit the support documents as per the the reimbursement process of the insurance company.

The normal TAT for a reimbursement claim is 14 days post submission of all relevant documents to the TPA/Insurance company.

Most of the insurance companies have almost the same set of documents that need to be submitted to the insurance company while filing a reimbursement claim. The list of documents include (but are not limited to):

• Duly Filled Claims Form
• Original Discharge Summary document
• Original Hospital Bill with detailed Cost Break-up + Original Paid Receipts
• Doctor’s Consultation Reports
• All Investigation, Lab and Test reports
• Detailed Break-up of Miscellaneous Expenses (If any)
• Copy of Invoice/Stickers/barcode in case of implants
• Medico Legal Certificate (in case of Hospital Cases)
• Photo Identity of Patient along with Health Card
• KYC documents

The process to be followed is very straightforward and simple:

1. Inform TPA/Insurance Company 48-72 hours before the actual hospitalization
2. Get admitted into the hospital as planned after submitting Health Card, Policy copy to the hospital insurance desk
3. Post treatment and at the time of discharge, settle the hospital bills in full and collect all the bills, receipts, supporting documents and reports
4. File a reimbursement claim with TPA/Insurance Company for processing and reimbursement by filling the claim form & enclosing all original bills/receipts/supporting documents and receipts
5. Reimbursement process normally takes 14 days post submission of all documents

Today the penetration of health insurance as a % of the overall population will be in the region of 15%. This is also because one of the most common types of health insurance is Group Health or Group Mediclaim, which is provided by employers to their staff as employee benefits. This is called group insurance. For Individuals and Family Floater policies, there are many channels currently available in India who sell health insurance. The include Agents (both Individual and Corporate), Banks, Brokers, Point of Sale (POS) persons, Insurance Marketing Firms (IMF) and the Insurance Web Aggregators (WA).

Most of the insurance plans in India can be broadly categorised under the following:

• Hospitalisation Plan– This is an indemnity plan which covers you for treatment and hospitalisation costs. For an individual policy, the insured sum is applied on a per member basis while in the family floater policy, the insured sum is applied on a floater basis.
• Top-up Plans– You already have Health Insurance provided by your employer but you want protection for situations that are not covered by your employer’s insurance plan. In this case, you can opt for a top-up plan.
• Critical Illness Plans–This plan will give the insured a lump sum amount when you’re diagnosed with any of the covered critical illnesses which can take care of the expenses to follow. Now many insurance companies offer more customised plans for Cancer, Heart and Diabetes Care which operate like the CI plans.
• Fixed Benefit Plans– these are plans like Hospital Cash which have a fixed benefit on a daily basis or plans that make a fixed payment irrespective of the expenses incurred for treatment.

No, most health insurance policies do not offer coverage for maternity and pregnancy related expenses. Since health insurance policies are designed to cover unforeseen and unexpected medical expenses a maternity/pregnancy is more a planned hospitalisation. Coverage for maternity expenses is one of the additional features offered by some of the insurance companies at a higher premium and with an appropriate waiting period. Check out the websitehttps://www.eindiainsurance.com/india-health-insurance/maternity-plans.aspto review some of the plans that cover Maternity.

In the unfortunate scenario of the primary insured passing away post hospitalization then the health expenses incurred would be reimbursed to the family. Also, if the primary insured happened to be the eldest member in the family, for succeeding years the premium would be calculated on the basis of the age of next eldest member. Also in the case where there were only two members covered under the policy then the family floater plan would be converted to an individual plan.

Yes, the insured can increase the Sum Insured of the plan they are currently insured under, but will be allowed to do it only at the time of renewal. They will need to apply to the insurance company for the same and will be done, subject to underwriting approval of the insurer.

Yes, this policy covers accident emergencies which require a period of hospitalisation for 24 hours or more. Health insurance policies provide accident coverage from the first day of the policy.

No, the claim made for a disease does not become the pre-existing disease for the next term as long as there is no break in the term of the insurance policy and it is renewed within the due date.

You can get hospitalised in any city in India. Cashless service is available only at the network hospitals of the insurer. The list of the hospitals is provided with your policy.
Note: For all the hospitals which do not come under the network you need to pay first and the insurer will refund you the money later.

There is no duration limit as such for stay in hospital but there is a limit to the amount offered by the insurers depending on company terms.

Health ID card, a photo identity proof (like Passport, Voter ID, driving licence etc) should be produced.

Insurance companies cover all advanced technological surgeries such as kidney stone removal, catheterization, chemotherapy etc. under Day care treatment and do not insist on 24 hours hospitalization in case of these procedures. The policy usually has the list of such treatments covered.

Your hospitalization expenses will be covered as long as the event that caused your hospitalization occurred during the policy period.

Yes, now there are a few companies which cover Non-Allopathic treatments.

'Domiciliary Hospitalization' covers you if any of the family members is treated at home. Only in case the patient's condition is such that he/she cannot be moved out of the home then the policy is applicable.

Health insurance policies usually have a 30 day waiting period from the policy start date in the case of sickness only. This clause is not applicable for accidents. Old age diseases like cataract, hysterectomy, hernia etc are usually given a waiting period of 1 – 2 years. The insurers specify these terms in the policy.