India Health insurance FAQ

It is a medical condition/disease that existed before the insured decided to buy a health insurance policy, and it is important because insurance companies do not cover such pre-existing conditions, within 36/48 months of prior to the policy inception. It means, pre-existing conditions can be considered for payment after completion of 48 months of continuous insurance cover and any claims within this period on account of such a pre existing condition will not be covered under the plan.

Ideally the renewal premium should be paid prior to the expiry date of the current year’s policy. However all insurance companies offer an additional window of15 days, called as Grace Periodafter the expiry date of the policy to allow the insured to pay the renewal premium. Failing to make the premium payment even during this grace period will result in the policy lapsing. Also, coverage would not be available for the period for which no premium is received by the insurance company.

Insurance Portability is the right granted to an individual health insurance policyholder to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another or from one plan to another plan within the same insurance company.The Insurance Regulatory and Development Authority of India (IRDAI) has issued a circular making it effective for the insurance companies to allow portability from one insurance company to another and from one plan to another, without making the insured to lose the renewal credits for pre-existing conditions, enjoyed in the previous policy. This means that if there is a waiting period of 48 months for a pre existing condition and the insured has already served 24 months under the existing policy, if he/she ports the policy to another insurer, then they will have to serve only the remaining 24 months of waiting period for pre existing diseases.

Expenses incurred during a time period prior to hospitalization are covered and known as Pre Hospitalisation expenses. Similarly Post Hospitalization expenses are those incurred by the insured for a specified period from the date of discharge. These expenses are considered as part of the claim provided the expenses relate to the disease / sickness for which treatment was sought and a claim filed by the insured.Normally

Any hospital in India which has a signed agreement with aTPA for providing Cashless treatment to the insured for covered medical treatment, is referred to as a Network Hospital. Most Network Hospitals also offer fixed and pre decided charges/rates for defined treatments/surgeries etc and commit to offering good quality treatment and services. They also confine to the pre conditions of the Medical Council of India in terms and beds and other facilities offered. Non-network hospitals are those who do not have agreementswith the TPA on terms and conditions and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim as per normal procedure.

After a claim is filed and settled, the policy coverage for that policy year is reduced by the amount that has been paid out on settlement. For Example: In January one starts a policy with a coverage of ₹5 lacs for the year and in April makes a claim of ₹2 lacs, thenthe sum insured/coverage available to for the remaining policy period (May to December) will be the balance of only ₹3 lacs. Under the Health insurance policy, any number of claims is allowed during the policy period unless there is a specific cap prescribed by the insurance company. However the sum insured is limited for the duration of the policy.

Some health insurance policies offer reimbursement coverage for the expenses incurred by the insured towards general health check-up once in a few years. Normally this is available once in four years. Recently some insurance companies are also offering reward points for wellness initiatives taken by the insured during the policy year, which help in discounting the renewal premium.

Some of the important Do’s and Don’ts for Health Insurance include:

Yes, in order to become eligible to make a claim under the health insurance policy, the minimum stay in the Hospital isatleast 24 hoursfor all treatments following an accident/sickness. This time limit however may not apply for some specific named treatments known asDay Care Procedures/Treatmentwhere in patient hospitalisation is not required to trigger a claim.

A day care procedure is a minor surgery or medical procedure that can be completed in less than 24 hours and doesn’t require prolonged hospitalisation of the insured. Thus, while the patient is in hospital for a short period of time, he/she does not spend a full 24 hours in the hospital, which is the minimum period for which claims can be filed. This is primary on account of technology advances in medicine and many surgeries these days are being conducted in short durations. Almost all insurance companies cover varying number of Day care procedures, some of which are listed below; one must however go through the policy terms and conditions to see the complete list of Day care procedures covered by the insurance company.

Yes, it is possible. You will be just a primary applicant and not the insured.

Yes, it is a mandatory for individuals or family members who are more than a certain age (usually 45, varies from company to company) to submit medical test report depending on the company regulations.

Yes, Health Insurance for those above the age of 45 years, require medical tests.

Most of the companies bare the cost of pre-medical check-up.

At the time of applying for the policy for the first time if there is any disease for any applicant this is known as Pre-existing diseases.

Most insurers do cover pre-existing diseases after a few years of insurance coverage. While it varies from company to company, pre-existing condition coverage is often covered after 2/4years provided you renew the policy with the same insurer.

Yes, it is necessary to disclose your existing health problems before buying policy. Since the insurers are not liable to any of the alteration of facts. At the time of buying policy one must know the diseases and the treatments he/she is going through.

At the time of filling an application for policy you have to disclose all the diseases for which you are currently undergoing treatment. The insurers refer to such health issues as pre-existing illnesses.

Does maternity expenses covered under the policy?