Clarify All Doubts Related Health Insurance

Mediclaim or health insurance policy is a basic health cover.Enter your basic details like your age, gender, whether you want to cover yourself or your family and a sum insured value. This value will be amount of cover according your needs and it is one of essential factor for premium calculation.

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 a 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 conditions?

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 a 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 tests 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.

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

Is the premium exempted from Income Tax?

Premium up to Rs.15000/- qualifies for tax benefit under Section 80D of the Income Tax Act.

If no claim has been made do I still have to premium at the time of renew?

Yes, you would be required to pay premium again.

How the premium rate for family floater plan is decided?

For family floater plan premium is charged on the basis of number of person covered and the age of the eldest member in the plan.

What is claim procedure?

Claim can be of two types:

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

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