Health Insurance is an insurance coverage that covers the cost of an insured’s individual medical and surgical expenses. Depending on the type of health insurance coverage, either the insurance company makes the payment directly to the network hospital (which is cashless settlement of claim) or the insured pays the cost out of his pocket and later receives reimbursement from the insurance company (which is a reimbursement claim).

Features of Health Insurance Policies in India

  • Cashless Settlement of claims: All of the health insurance companies in India offers cashless settlement of claims at network hospitals.
  • In Patient Treatment: Policy covers for hospitalization expenses due to disease / illness / injury during the policy period that requires an insured person's admission to hospital as an inpatient.
  • Initial Waiting Period: There is initial waiting period of 30 Days for normal illness. Whereas the coverage is from day one for hospitalization claims due to an accident. However, this is not applicable for person who is previous insured under a retail health insurance policy of any insurance company in India.
  • Pre & Post Hospitalization Expenses: Policy pays for pre and post hospitalization expenses for 30 days & 60 days respectively.
  • Room Rent Capping: It is sub-limit in your health insurance policy. In health insurance, insurer can provide you with a maximum coverage up to the sum assured. However, they can deliberately trim down their liability by introducing the sub-limit clause in the coverage for hospital room rent. A sub-limit on room rent in case of hospitalization works on per day basis. For instance, if your medical insurance is for sum insured of INR 300000/- & suppose your health insurance policy has room rent capping of 1% for normal room. Then if the insured had taken room having tariff of INR 5000/- per day, in that scenario he has taken room tariff higher than his eligibility in health policy (His health policy permits him for room rent of 1% of sum insured which is INR 3000/- per day). Under such circumstances he will be liable to pay for 2000/- per day for room rent. And if his final hospitalization bill comes out to INR 200000/-, he will be forced to pay INR 80000/- (which is 2/5th of INR 200000/-). Thus, by having capping in room rent, insured will be forced to pay proportionately in is final hospitalization bill for the same ratio in which the co-payment for excess room rent was payable.

    Overall copayment in hospitalization Bill  =  (Excess of room tariff over room rent allowed in policy  X  Final Hospitalization bill)  /  Actual room tariff taken by insured

    Hence choosing a health insurance policy with no capping on room rent is always advisable.
  • Pre – Existing Diseases: Generally, they are covered after four consecutive years of continuously insured in a health insurance policy (either of same insurance company or in multiple insurance companies if the policy is ported by insured in such period). A pre-existing disease is a medical condition of the insured as on date of taking the health insurance policy. In case insured is having any ailment or taken any medical procedure or taking any medicines then he is supposed to declare those pre-existing diseases on the proposal form
  • No Claim Bonus: NCB (or No Claim Bonus) is a bonus provided to the insured if the no claim has been filed for any treatment in the previous policy year. NCB is offered as an increment in the sum assured. You can avail this advantage on policy renewal.
  • Day Care Procedures: A health insurance policy also pays for all day care prodecures that doesn’t require 24 hours of hospitalization.
  • Restoration of Sum Insured / Re-instatement of sum insured: Now a day’s good private sector insurance companies offer this feature in health insurance policy. If insured sum insured is exhausted in a medical treatment there is provision for restoration of sum insured. This benefit triggers once the claim is settled and the sum insured must be exhausted in that claim. However it is to be noted that the sum insured so restored can’t be utilized for same insured’s same illness for the unexpired period of his health insurance policy.
  • Second Opinion: Many of the insurers have the provision to facilitate for second option to insured to make them comfortable in belief that the course of treatment given at network hospital is as per medical practise.
  • Ambulance Cover :The insured person is free from burden of transportation fee as it is borne by the insurer. This is an addon benefit and most of the insurers offer it a package benefit in health insurance with some sub limits.
  • OPD treatment: Though it is not covered in most of the health insurance policies but some of the companies had launched few health insurance plans where they offer OPD benefit but that too with some sub-limits. Premium charged in such plane are usually higher than normal health insurance premium rates.
  • Maternity Cover: Usually it is not covered in standard health insurance policy. However, few companies offer to cover maternity but that too with waiting period of two years. Premium charged in such plane are usually higher than normal health insurance premium rates.
  • Medical Check-Up: Under health insurance, the insured is entitled to receive regular medical check-ups. Generally, this benefit is available if you have a good history of no-claim bonus. Benefit is available in block of few claim free years. However, few companies offer this benefit on every renewal.
  • No of lives that can be covered: 2 Adults + 3 kids / 2 Adults + 4 kids
  • AYUSH treatment: Few of the companies offer benefit for payment for AYUSH treatment as well but that will be within few sub limits.