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Health Insurance Policy

A Health Insurance Policy is a type of insurance that takes care of your medical expenses that arise due to a illness. This insurance also ensures that you can avail cashless treatment at a network hospital without having to pay for them. Health insurance is a must have policy keeping in mind the high cost of treatments in current era.

Health Insurance Policy
Introduction
Who can take this Policy?
Coverage
Add on Covers
Basis of Sum lnsured
Exclusions

Health Insurance is a type of insurance that indemnifies financial loss for medical expenses, in case of a medical emergency. A health insurance plan provides many benefits, including cashless hospitalization, day-care facility & coverage for terminal & critical illness etc.

Any individual can take this policy provided there age is 18 years for adults and 91 days for dependent children. The cover can be taken for self or family members.

  • In patient hospitalization expenses
  • Pre-existing diseases
  • Pre-post hospitalization
  • Maternity or newborn
  • Health check ups
  • Daycare procedures
  • Room charges
  • Domiciliary hospitalization
  • Ambulance charges
  • Air ambulance
  • Ayurveda treatment
  • OPD treatment
  • Donor expense, case of organ transplant
Age, Medical requirements of family, cost of medical treatment on your city, Medical history.
There are some standard exclusions for Individual Health Insurance Policy:
  • Pre-existing diseases
  • Non-allopathic treatments like Ayurvedic and homeopathic treatments
  • Illnesses arising due to use of intoxicating substances like alcohol and drugs
  • Cosmetic and aesthetic treatments
  • Self-inflicted injuries
  • War and allied perils
  • HIV
  • Congenital diseases

IMPORTANT POINTS TO REMEMBER WHILE BUYING THE POLICY

Avoid cappings (limits/sub limits) in the policy

  • Avoid cappings (limits/sub limits) in the policy as it can lead to deduction of claim

Never miss the renewal to avail the continuity benefit

  • Never miss the renewal to avail the continuity benefit as pre existing disease would have few years of waiting period in new policy.

Go for long term policy to get the discount on premium

  • It is recommended to go for long term policy to get the discount on premium

Key Documents at The Time Of Claims

General Claim
Intimation Format
Immediate Action Client
Should Take
Indicative General Documents
for Settlement of Claims

Why Choose Us?

Professional & Experienced Team
Professional & Experienced Team
Customized Solutions
Customized Solutions
Strong Relationship With Insurance Companies
Strong Relationship With Insurance Companies
Service Commitment ONTIME EVERYTIME
Service Commitment ONTIME EVERYTIME
Technological Edge
Technological Edge
Additional Services Offered
Additional Services Offered
Competitive Premium
Competitive Premium
Single Window Solution
Single Window Solution

Downloads

Proposal Form  
Policy Wordings  
Claim Form  

FAQ's

PREMIUM
COVERAGES
CLAIMS
OTHERS
  • Do I get cover for pre-existing diseases?
    Yes, but after a specified waiting period provided it is renewed continuously for the same period.
  • Am I entitled for cover immediately after taking out policy?
    No, any illness contracted within 30 days from the day of inception of the policy is not covered except for injuries from accidents.
  • Which diseases are not covered just from the inception date of the policy?
    • Any illness/ disease/ injury/ pre-existing disease before the inception of the policy. However, this exclusion ceases to apply if the policy is renewed with the Company for 4 consecutive years
    • Non-allopathic treatment, pregnancy and childbirth related complications, cosmetic, aesthetic and obesity related treatment
    • Expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self injury
    • War, riots, strike, nuclear weapon, induced treatment
  • What is claim procedure?

    Claim can be of two types:

    1. Planned

    Where the member of the covered family is aware of the hospitalization 2-3 days in advance. In case of planned hospitalization:

    • Please contact your Service provider or TPA help-line mentioned in the Health Identity Card
    • Fax / submit the required documents. E.g. Doctor's certificate, medical bills etc.
    • Obtain approval from the Service Provider or TPA

    2. Emergency

    Where the insured meets with sudden accident or suffers from bout of illness that requires immediate admission to the hospital. In case of emergency hospitalization

    • The patient is to be rushed to the hospital
    • Patient avails treatment
    • Family to contact Service Provider or TPA help-line as mentioned in the Health Identity Card

    The claims are serviced at both network and non-network hospitals.

  • What are the documents required for filing a claim?
    The following are basic documents required for filing a claim:
    • Duly completed claim form
    • Original bills, receipts and discharge certificate/ card from the hospital
    • Original bills from chemists supported by proper prescription
    • Receipt and investigation test reports from a pathologist supported by the note from attending Medical practitioner / surgeon prescribing the test.
    • Nature of operation performed and surgeon's bill and receipt.
  • If I have health insurance from two different insurers can I claim twice for same treatment?
    No, you cannot claim twice for single expense.
  • What is cashless hospitalization?
    Cashless hospitalization is a facility provided by the insurers wherein the insured can get admitted and undergo the required treatment without paying directly for the medical expenditure. The medical expense, thus incurred, shall be settled by the company directly with the hospital. The Cashless claim facility can be obtained only at the hospital network the service provider has a tie-up with.
  • What is a Reimbursement claim?
    In case of a reimbursement claim, the insured pays the expenses himself with the hospital and then claims for a reimbursement of those expenses.
  • What is Pre-Authorization?
    Pre-authorization is basically an authorization issued either by the insurance company or the service provider, specifying the value of the medical treatment that can be claimable under their insurance policy. To receive a pre-authorization, you need to submit duly fill in the Pre-authorization form.
  • What are Network and Non-network Hospitals?
    Network Hospitals:The company ties up with hospitals for cashless claim process. When you avail of a cashless treatment in any of these network hospitals, the company would settle the claim with the hospital directly. For a complete list of network hospitals, log on to Service Provider's or TPA's website. Hospital network list of each Service Provider or TPA may vary.
    Non-Network Hospitals:Non network hospitals are the ones with which the company does not have a cashless tie up. When you avail treatment here, you first settle the bills yourself and then submit the relevant documents and bills to the service provider or TPA. The amount, consequently, is reimbursed to you based on policy terms and conditions.
  • How dose one get reimbursements in case of treatment in non-network hospitals?
    Cashless hospitalization is available only in network hospitals. You are at liberty to choose a non-network hospital also. In case you avail treatment in a non-network hospital, insurer will reimburse you the amount of bills subject to the policy taken by the policyholder. Note: Only expenses relating to hospitalization will be reimbursed as per the policy taken. All non-medical expenses will not be reimbursed.
  • What is Health Insurance?
    Health Insurance is a type of insurance whereby the insurer pays the cost of hospital and medical care of the insured if the insured become sick due to covered causes, or due to accidents.
  • What is Family Floater Plan?
    A Family Floater is a single policy that takes care of the hospitalization expenses of your entire family. The premium charges in this plan depend on the age of eldest member in the family going for cover.
  • Do I have to undergo any medical examination?
    Medical examination may be required in some cases, based on the sum assured and the age of the person. But if you are aged above 55 most of the insurers will ask you to undergo medical examination.
  • What is Meant by Pre and Post Hospitalization?
    Pre- and Post-hospitalization expenses cover all relevant medical expenses incurred 30 days prior to hospitalization and expenses incurred during 60 days after hospitalization. Relevant expenses means all expenses pertaining to the disease for which one is hospitalized.
  • What is meant by Pre-existing disease or condition?
    Pre-existing disease is a disease or a condition existing in a person before the acceptance of the risk. The insured or a person buying the policy may or may not be aware of these conditions. These conditions may aggravate and lead to serious medical conditions in the future.
  • What is waiting period?
    A waiting period is the length of time the insured may have to wait before being eligible for some of the health policy benefits.
  • What are the basic medical test an adult needs to go through if it is required by the insurer?
    An adult has to undergo the following medical test:
    • Complete Blood count
    • Fasting Blood Sugar
    • ESR
    • Serum Creatinine
    • SGPT
    • Urine Routine
    • ECG
    • Medical Examination with BP recordings - By a physician

    An additional charge would be collected for the Medical Test from you.

Claim Case Study - 1

1
Situation

Room Rent Capping/Restriction.

2
Challenge

Customer will have to pay a sizeable amount at the time of discharge because of room rent capping.

3
Solution

Customer should select the room according to the policy’s room rent limit to avoid payment of difference from their own funds.

4
Advisory/Conclusion

Always go for a policy with no room rent capping to avoid such situations.

Claim Case Study - 2

1
Situation

Generally insured does not get the original reports (MRI/X-Rays/USG Report) returned from TPA/Insurance Company after the settlement of claim.

2
Challenge

Limited knowledge how to get these reports (MRI/X-Rays/USG Report) returned from TPA/Insurance Company.

3
Solution

As a right you can claim the original reports (MRI/X-Rays/USG Report) from the TPA / Insurance Company after 15 days subsequent to settlement of claim. It is the responsibility of your insurance broker to get it done on your behalf.

4
Advisory/Conclusion

You should always intimate to the TPA / Insurance Company well in advance that you need these original reports returned after the claim settlement.

INSUROLOGY

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