Glossary

The sum insured, in simple terms, is the maximum coverage amount you can get in a policy year. It forms the basis of all your claims. Consider the increasing costs of hospitalization, medicines, and treatment before you decide on your sum insured. It’s advisable to select a higher cover. At the same time, the cover shouldn’t be high enough for you to dig into your pockets for paying the premium.

Some health insurance companies have introduced the co-pay and sub-limit system to prevent hospitals from billing unreasonable room rents to patients. In a co-pay policy, you need to pay a part of the expenses irrespective of the sum assured. For instance, if a policy has 10% co-pay, then the insurance company will pay 90% of the expenses and you have to bear the rest.

Besides, some insurers cap the expenses of treatments to reduce the claims of hospitals. This is known as sub-limit. For instance, if the insurance policy states that the hospital bed cost will be 1% of your sum assured, then it’ll pay Rs2,000 against a 2 lakh sum assured, for each day of hospitalisation. But if the hospital charges you Rs3,200 in this regard, then you have to pay the balance Rs1,200 from your own pocket.

While buying a mediclaim, choose a policy which has fewer sub-limits. Some mediclaim policies have no co-pay or sub-limits. Try to select such a plan.

Pre-hospitalization expenses include various charges related to medical tests before an individual gets hospitalized. Doctors/physicians conduct a slew of tests to accurately diagnose the medical condition of a patient before prescribing treatment. It is important to note that the number of days which are covered, tends to vary depending upon the type of health insurance provider. However, in most cases, charges incurred by an individual 30 days prior to his or her admission to any hospital fall within the ambit of pre-hospitalization expenses. For instance, several tests such as blood test, urine test and X-ray among others are categorised as pre-hospitalization expenses.

Post hospitalization expenses include all expenses or charges incurred by an individual after he or she is hospitalized. For instance, the consulting physician may prescribe certain tests to ascertain the progress or recovery of a patient. It is important to note that the number of days which are covered tends to vary depending upon the type of health insurance provider. However, in most cases, charges incurred by an individual for 60 days from the discharge date comes under the ambit of post hospitalization expenses. Expenses related to various therapies, namely, acupuncture and naturopathy are not included by insurance providers in the category of post hospitalization expenses. However, diagnostic charges, consulting fees and medicine costs are covered.
An individual can claim both pre and post hospitalization expenses upon submission of original bill receipts and relevant copies of doctor’s certificate and discharge summary. Policyholders should have detailed knowledge of the list of inclusions in their health insurance policies to avail of the maximum benefits from them.

Some employers provide health insurance to their staff under group insurance plan. But you can still have a mediclaim of your own which covers the entire family. You may not consider having a second mediclaim policy if your employer allows you transfer the policy if you leave your job. It’s important that you compare several policies before buying one.

The restore benefit feature allows reinstating your basic sum assured, if you have  exhausted part or full sum insured after a claim under your policy.

Insurers usually extend a NCB to a policyholder if there has been no claim in the preceding year. While buying a mediclaim, check the NCB amount before signing on the dotted lines. NCBs can range from 5% to even 100% of the sum insured. A high NCB gives cover against medical inflation and you don’t need to worry about increasing your coverage year-on-year.

Pre-existing diseases are the ones you have while subscribing to the mediclaim policy. Most health insurance companies specify a waiting period for these illnesses. If you have a pre-existing illness, the insurance company is unlikely to give a cover against the same. In most cases, a pre-existing illness is covered after at least three years of buying the policy.

Waiting periods refers to the time period for which the treatment of some specified diseases is not payable under the policy. This means that whether at the time of taking the policy, whether a person is suffering or not suffering from these specified diseases, the treatment for these specific diseases are not payable under the policy. Diseases such as Cataract, Hernia, Gall Bladder Stone, Cysts or in simple terms, minor operations which we can hold are not payable under the waiting period.

 
Exclusions simply mean the diseases that are not covered under the mediclaim. For instance, expenses occurred for the treatment of diseases due Alcohol/Drug abuse, self indicted injury, AIDS or cosmetic treatments are generally excluded under the Mediclaim policy.

Some newly launched Medical insurance policies provide cover on hospitalization that doesn’t require overnight stay. These are called daycare procedures. Check out how many procedures are covered in the plan. Also, most insurers don’t consider maternity as medical emergency. So don’t look for a maternity cover if you have no plans for a baby.

Medical costs are increasing. It calls for large covers. But not all can afford a high premium. A top up plan can come useful in such a case. It reduces cost of deductibles i.e. the amount you pay before the insurance company pays up. The insurance company will only pay up to the sum assured. A top up plan, on the other hand, doesn’t pay until the hospital bill breaches a specific limit. Say, if the hospital bill is Rs8 lakhs with Rs3 lakhs as deductible, you need to pay the latter, while the insurer pays the balance Rs5 lakhs. But you can use your individual/group policy to pay the deductible amount. This is usually helpful because combination of a basic mediclaim plan along with a top up plan is much cheaper than a single cover. For instance, premium for a Rs5 lakhs regular cover for a 26-year old male, will be around Rs6,500. A top up with Rs15 lakh cover will entail an additional premium of Rs5,000, which is far cheaper than a standalone policy of identical amount.