A Health Insurance Policy would normally cover expenses reasonably and necessarily
incurred under the following heads in respect of each insured person subject to
overall ceiling of sum insured (for all claims during one policy period).
- Room, Boarding expenses
- Nursing expenses
- Fees of surgeon, anesthetist, physician, consultants, specialists
- Anesthesia, blood, oxygen, operation theatre charges, surgical appliances,
medicines, drugs, diagnostic materials, X-ray, Dialysis, chemotherapy, Radio therapy,
cost of pace maker, Artificial limbs, cost or organs and similar expenses.
The Sum Insured offered may be on an individual basis or on floater basis for the
family as a whole.
Cumulative Bonus (CB)
Health Insurance policies may offer Cumulative Bonus wherein for every claim free
year, the Sum Insured is increased by a certain percentage at the time of renewal
subject to a maximum percentage (generally 50%). In case of a claim, CB will be
reduced by 10% at the next renewal.
Cost of Health Check-up
Health policies may also contain a provision for reimbursement of cost of health
check up. Read your policy carefully to understand what is allowed.
Minimum period of stay in Hospital
In order to become eligible to make a claim under the policy, minimum stay in the
Hospital is necessary for a certain number of hours. Usually this is 24 hours. This
time limit may not apply for treatment of accidental injuries and for certain specified
treatments. Read the policy provision to understand the details.
Pre and post hospitalization expenses
Expenses incurred during a certain number of days prior to hospitalization and post
hospitalization expenses for a specified period from the date of discharge may be
considered as part of the claim provided the expenses relate to the disease / sickness.
Go through the specific provision in this regard.
Insurance companies have tie-up arrangements with a network of hospitals in the
country. If policyholder takes treatment in any of the net work hospitals, there
is no need for the insured person to pay hospital bills. The Insurance Company,
through its Third Party Administrator (TPA) will arrange direct payment to the Hospital.
Expenses beyond sub limits prescribed by the policy or items not covered under the
policy have to be settled by the insured direct to the Hospital. The insured can
take treatment in a non-listed hospital in which case he has to pay the bills first
and then seek reimbursement from Insurance Co. There will be no cashless facility
Additional Benefits and other stand alone policies
Insurance companies offer various other benefits as “Add-ons” or riders. There are
also stand alone policies that are designed to give benefits like “Hospital Cash”,
“Critical Illness Benefits”, “Surgical Expense Benefits” etc. These policies can
either be taken separately or in addition to the hospitalization policy.
A few companies have come out with products in the nature of Top Up policies to
meet the actual expenses over and above the limit available in the basic health