Category: Health Insurance

The right to not demand/ enforce certain conditions that are typically expressed & characteristic of a policy.

Sub-limit is a disease wise limitation on the claim amount. The amount of claim for a specific disease will be limited as per terms of the policy. In other words, it places a maximum limit of amount payable for treatment of one type of disease. Sub-limits are generally included for diseases such as hernia, cataract, maternity and other ailments or procedures, depending on the Insurer & their corresponding policy terms.

This is the procedure by which the policyholder pays for treatment upfront to the Hospital from their own pocket, and claim it later from the Insurer. After submission of bills, the Insurer verifies the bills and pays the amount if found in order.

Certain charges like registration fees, duty doctor charges, consumables such as gauze, syringes, etc., towards non-medical expenses and others charged by a hospital during inpatient treatment are not paid by the Insurer as a standard.

These are conditions or diseases or risks for which an insurance Claim is not allowed, and the insured will not be given any benefit. As per Policy terms such conditions will be excluded from the insurance coverage. Exclusions can be of two types – Permanent & exclusions with waiting period. Permanent exclusions are never covered.

A family floater policy is issued with a single sum insured covering number of individuals of the same family. Simply put, it is a one premium and one policy for all members of the family. The cover can be used by any member of the family any number of times, limited to the sum insured.

If co-pay is opted in an insurance policy, the insured has to pay a fraction of the claim amount. Co-payment is shown as a percentage of the total claim amount. If co-pay is included in the Insurance Policy, the premium will be lower.

For example, if the total hospital expenditure is ₹1,00,000/- and if the co-pay is agreed at 20%, then the insured has to pay an amount of ₹20,000/- and the balance of ₹80,000/- will be paid by the Insurance Company.

Upon availing services/ procedures in an Insurer’s Network Hospital, the policyholder will not be required to pay for the treatment, and the Insurer through the TPA will directly pay the hospital.

IRDAI licensed Third Party Administration process the claims under health insurance on behalf of the Insurance Companies, on a fee-for-services basis. Their responsibilities typically include claims administration, loss control, co-ordination for cashless claim settlements and risk management consulting.

Waiting period for a specific disease/ailment is the period from the inception of policy within which claims will not be accepted for any treatment related to that disease. The policy holder has to pay the premiums for the waiting period and such claims will be accepted after the waiting period is over.