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FAQ On Benefits and Coverages Under the Health Insurance in India

   
  1. What is Health Insurance/Mediclaim?
  2. Why do I need Health Insurance?
  3. What are the salient features of this policy?
  4. What is covered under Hospitalization Benefit?
  5. What are the circumstances under which the condition of minimum 24 hrs hospitalization does not apply?
  6. What are the expenses covered under Hospitalisation Expenses?
  7. What is Domiciliary Hospitalization?
  8. What do you mean by Pre and Post hospitalization?  
  9. For how many days would the pre and post hospitalization expenses be covered?
  10. What do you mean by Pre-Existing Diseases?
  11. What is meant by Donor Expenses?
  12. How much is the sum insured?
  13. What is Family Floater and what are its advantages?
  14. Is there an Income Tax exemption on the premium? If yes, under which section and what is the Income Tax exemption limit?
  15. What is Cumulative Bonus?
  16. What is the maximum cumulative bonus one can accumulate in a mediclaim policy?
  17. If I have accumulated cumulative bonus on my policy for the last three years and I have a claim in the fourth year, will I lose my C.B.?
  18. Do I get a discount on renewal of the policy with the same company?
  19. What is the “First 30 days Exclusion”?
  20. What are first year/ second year exclusions?
  21. Enlist some of the important exclusions under mediclaim policy.
  22. Can a person have more than one Health policy?
  23. Can I cancel my policy and if yes will I get my premium back?
  24. What are the medical tests that I need to undergo to enroll myself? And who will bear the cost?
   
  1. What is Health Insurance/Mediclaim?
  Health Insurance/Mediclaim is protection against medical costs. A health insurance policy 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 (cashless facility) or reimburses the expenses associated with illnesses and injuries.

Mediclaim Insurance is a cover, which takes care of the hospitalization expenses subject to maximum sum insured of the Insured in respect of the following situations:

A. In case of a sudden illness.
B. In case of an accident.
C. In case of any surgery, which is required in respect of any disease which has arisen during the policy period?
 
     
  2. Why do I need Health Insurance?  
  Healthcare is expensive. Technological advances, new procedures and more effective medicines have driven up the cost of healthcare. This increase has to be borne by the consumer making treatment unaffordable for too many. Health Insurance overcomes these obstacles so that you remain free of anxiety regarding your health. Think for a moment about the enormous medical costs you would incur if you suffered a major accident tomorrow or were suddenly stricken by an illness. Uninsured people live with such risks everyday. Health insurance seeks to shield you from that risk. It provides the much needed financial relief. You also get tax benefit under section 80D of the Income Tax Act.  
     
  3. What are the salient features of this policy?  
  Though the features may vary from insurer to insurer, some basic features are:

1 Reimbursement for Hospitalization due to illness/disease/ surgery.

2 Reimbursement for Domiciliary Hospitalization expenses in lieu of Hospitalization.

3 Pre-hospitalization expenses

4 Post-hospitalization expenses

5 Ambulance Charges

6 Cashless Access

7 Income Tax Benefit etc.
 
     
  4. What is covered under Hospitalization Benefit?  
  1 Expenses on Hospitalization for a minimum period of 24 hours.

2 In case of treatments like Dialysis, Chemotherapy, Lithotripsy, Radiotherapy, Eye surgery, Dental Surgery, Tonsillectomy, D&C taken in Hospital/Nursing Home, the time limit of 24 hours is not applicable.
 
     
  5. What are the circumstances under which the condition of minimum 24 hrs hospitalization does not apply?  
  This condition will not apply in the following cases:

1 the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in Hospitals.

2 due to technological advances hospitalization is required for less then 24 hours only.
 
     
  6. What are the expenses covered under Hospitalisation Expenses?  
  Hospitalization expenses incurred as an in-patient in a Hospital include:

1. Room, Boarding Expenses as provided by the Hospital/Nursing Home.

2. Nursing Expense.

3. Fees of Surgeon, Anesthetist, Medical Practitioner, Specialists, Consultants.

4. The cost of anaesthesia, diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs, operation theatre charges, Dialysis, Chemotherapy, Radiotherapy and similar expenses.
 
     
  7. What is Domiciliary Hospitalization?  
  Domiciliary Hospitalization means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely:

i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or

ii) The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein
 
     
  8. What do you mean by Pre and Post hospitalization?  
  Relevant medical expenses incurred before and after hospitalisation for a specified number of days. Relevant medical expenses means expenses related to the treatment of the disease for which the insured is hospitalised.  
     
  9. For how many days would the pre and post hospitalization expenses be covered?
 
  The period varies according to the insurer and the plan opted for.  
  Insurer Pre hospitalization/Post hospitalization  
  National Individual 30 days/60 days  
  National Parivaar 15 days/30 days  
  National Varistha 30 days/60 days  
  New India 30 days/60 days  
  United 30 days/60 days  
  Oriental 30 days/60 days  
  Bajaj Allianz 60 days/90 days  
  ITGI 30 days/60 days  
  Royal Sundaram 30 days/60 days  
  Reliance Gold and Silver Plans 60 days/90 days  
  Reliance Standard Plans 30 days/60 days  
     
  10. What do you mean by Pre-Existing Diseases?  
  Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company. Pre existing diseases will be covered after a maximum of four years since the inception of the policy.  
     
  11. What is meant by Donor Expenses?  
  All hospitalization expenses incurred by the donor for donating an organ (excluding the cost of the organ) to the insured during the course of an organ transplant.  
     
  12. How much is the sum insured?  
  Sum insured is the amount of coverage taken by the insured by paying the Premium plus the Cumulative Bonus accumulated in the policy, if available.  
     
  13. What is Family Floater and what are its advantages?  
  Family Floater is a policy wherein the entire family of the insured, comprising of insured, spouse and two dependent children, is covered under single sum insured.

The advantages of such a policy are:

1. All members of the family (as defined above) can be covered under one policy.

2. Single Premium is payable for the entire family.

3. The amount of Sum Insured floats over the entire family i.e. the limit can be used by any member of the family and for any number of times.

4. One does not have to keep a track of renewals for different members; a single renewal date is to be remembered.
 
     
  14. Is there an Income Tax exemption on the premium? If yes, under which section and what is the Income Tax exemption limit?  
  Yes, Premium paid for mediclaim policy is eligible for tax deduction under section 80 D of the Income Tax Act, subject to the condition that the premium amount is paid by cheque/DD by the customer from his bank account.

As per current IT rules you can get an exemption up to a maximum sum of Rs.10000 from your taxable income under Section 80-D for Health Insurance Premium paid for self, spouse, dependent children and dependent parents and Rs 15000 if the policy includes senior citizens whose ages is above 65 yrs.
 
     
  15. What is Cumulative Bonus?  
  An increase in the Sum insured by a specified percentage for every claim free year, subject to a certain maximum. An important point to be remembered is that the policy should be renewed without a break to avail of the C.B.  
     
  16. What is the maximum cumulative bonus one can accumulate in a mediclaim policy?  
  5% increase in Sum Insured every claim free year, subject to a maximum accumulation of 10 claim free years i.e. maximum 50% C.B.  
     
  17. If I have accumulated cumulative bonus on my policy for the last three years and I have a claim in the fourth year, will I lose my C.B.?  
  In this case the increased percentage will be reduced by 10% of sum insured at the next renewal. However, the basic SI will be maintained and will not be reduced.  
     
  18. Do I get a discount on renewal of the policy with the same company?  
  Some companies offer a renewal discount of 5% of renewal premium if there are no claims in the expiring policy period. This can be accumulated to a maximum of 50%.Under certain plans such as National Varistha the insured has an option to either avail cumulative bonus or renewal discount.  
     
  19. What is the “First 30 days Exclusion”?  
  Any expenses on hospitalization/domiciliary hospitalization incurred during first 30 days from the date of commencement of insurance cover, except in case of injury arising out of accident, are not payable.  
     
  20. What are first year/ second year exclusions?  
  During the period of insurance cover, the expenses on treatment of certain diseases such as cataract, hernia, piles, sinusitis, benign Prosthetic Hypertrophy, Hysterectomy for Menorrhegia or Fibromioma etc. for specified periods (Please refer to your policy document for details) are not payable if contracted and/ or manifested during the currency of the policy.  
     
  21. Enlist some of the important exclusions under mediclaim policy.  
 

Some general exclusions under this policy are:

1 Pre-existing diseases i.e. Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company. Pre existing diseases will be covered after a maximum of four years since the inception of the policy

2. Any disease contracted during the first 30 days of inception of policy except in case of injury arising out of accident

3. Certain diseases such as cataract, piles, hernia, and sinusitis etc. are excluded for specified periods if contracted or manifested during the currency of the policy.

4. Injury or Diseases directly or indirectly attributable to War, Invasion, Act of Foreign Enemy, War like operations.

5. Cosmetic, aesthetic treatment unless arising out of accident.

6. Cost of spectacles, contact lenses and hearing aids

7. Dental treatment or surgery of any kind unless requiring hospitalization

8. Charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations, without any treatment.

9. Naturopathy or other forms of local medication

10. Pregnancy & childbirth related diseases

11. Intentional self-injury / injury under influence of alcohol, drugs

12. Diseases such as HIV or AIDS

13. Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the attending physician.

14. Convalescence, general debility, run-down condition or test cure, congenital external diseases or defects or anomalies, sterility, venereal disease.

 
     
  22. Can a person have more than one Health policy?  
  Yes. But each company will pay its rateable proportion of the loss, liability, compensation, costs or expenses. E.g. If a person has Health Insurance from company X for Rs. 1 Lac and Health Insurance from company Y for RS. 1 Lac, then in case of a claim, each policy will pay in the ratio of 50:50 up to the SI.  
     
  23. Can I cancel my policy and if yes will I get my premium back?  
  Yes, the insured can cancel the policy at any time. In such a case, the company shall allow a refund of premium at company’s short period rate(given below) provided no claim has occurred during the policy period up to cancellation.  
  Period of cover up to Rate of premium to be charged  
  1 month ¼ of the annual rate  
  3 months ½ of the annual rate  
  6 months ¾ of the annual rate  
  More than 6 months Full annual rate  
     
  24. What are the medical tests that I need to undergo to enroll myself? And who will bear the cost?  
  Medical tests required are Blood/Urine sugar, Blood Pressure, ECG and Eye check up including retinoscopy. The cost has to be borne by the insured.  
     

FAQ Disclaimer

Health Insurance Benefits FAQ are provided for informational purposes only. We don't guarantee on the accuracy of these answers as answers for some of the questions may change from time to time as and when insurance companies or industry change their policies/rules. Please refer to the policy wording for more detail. Please read our Legal Disclaimer in this regard.