Health Insurance Terms and Conditions: Importance, Types and Cover
Health insurance policies provide financial coverage against expenses arising due to medical emergencies. These help to account for hospital-related expenses, daycare procedures, room rents, doctor’s fees, nursing and boarding charges, ICU charges, etc. That said, all health insurance policies come with unique terms and conditions, and they vary among plans.
With so many different policies having unique coverage, inclusions, and exclusions, people need to read their health insurance terms and conditions carefully. This will let them avoid getting their claims rejected and let them access financial assistance during times of great need.
Why Read the Health Insurance Terms and Conditions ?
A medical insurance policy is like an umbrella providing financial protection during times of need. However, with so many choices of health policies available, it is important to make an informed decision before choosing a health plan.
Therefore, you should always check the health insurance terms and conditions to understand if they suit your needs. Another reason to read the policy documents is that people often forget about the specifics of clauses until they need to make claims. Knowing the terms early will avoid claims rejection in times of crisis.
The following are some important terms and conditions that you should pay special attention to:
- Type of health insurance policy
- What the policy covers
- Scope of the coverage
- Standard exclusions
- Cost of the plan
- List of network hospitals
- Conditions of portability
- Discount (if available)
- Out-of-pocket costs and deductibles
- Maximum number of claims you can file in a year
- The clause regarding pre-existing diseases
- Restrictions on expenses
Additional Factors to look for in Health Insurance Terms and Conditions
Look for these clauses in the terms and conditions before buying a policy:
1. Sum Insured
When choosing a health insurance policy, you should select one with a sum insured amount that is enough to cover potential needs. For example, if you have pre-existing conditions, it may be worth paying a higher premium for coverage of specific illnesses.
2. Claim Process
The objective of a health plan is to get paid for any legitimate claim during times of need. Therefore, you should choose an insurer that follows simple and fast claim processing and have good customer support.
3. Network Hospitals
They allow you to get treatment without paying any cash as they are directly associated with the insurer. The more hospitals are included in the insurer’s network, the easier it is to get the cashless facility from anywhere, especially during an emergency.
4. Waiting Period
You have to wait before raising a claim under your health insurance policy. Make sure to choose the policy with the least waiting period to avoid being in a medical emergency with no health cover.
5. Co-payment Clause
This clause in medical insurance policy refers to a certain percentage of the claim amount one has to pay out of pocket when making a claim. A higher co-payment decreases your out-of-pocket expenses but increases your financial burden during medical emergencies.
6. Lifelong Renewability
Some health insurance policies offer the option to renew it every year. Choosing a health plan with a lifelong renewal facility is beneficial as it lets you avoid higher premiums due to age.
Type of Health Insurance Plan You Have Chosen
Health insurance products come in different types for different needs. Check the policy terms to know what type of health plan you are buying.
- Individual health insurance policies
These plans cover medical expenses for injury, accidents, medicines, room rent, etc., for one individual only. - Family floater health insurance policies
Instead of buying separate insurance policies for different family members, one can get a single-family floater policy covering the entire family. - Group/employee health insurance policies
Employers of medium to large size enterprises buy these plans for their employees. - Senior citizen health insurance policies
These health plans come with higher premiums but offer full coverage and high sum insured, ideal for senior citizens. - Critical illness benefit plans
These policies provide a high insured lump sum for certain life-threatening diseases such as cancer, heart attack, and kidney failure. - Personal accident insurance policies
These provide compensation for disablement, injury or death by unforeseen accidents.
Common Coverage of Health Insurance Plans
Depending on the insurer and the specific policy terms, a health insurance plan can offer the following coverage.
1. Hospitalisation Expenses
It includes all medical expenses incurred after the patient gets admitted to a hospital for over 24 hours. For example, it covers room rent, medicine costs, diagnostic test charges, doctor’s fees, etc.
2. Pre and Post-hospitalisation Expenses
This includes medical charges for a specific number of days before admission and follow-up treatment costs after discharge.
3. Daycare Expenses
Some medical treatments do not require the patient to get admitted for 24 hours. Daycare expenses include these advanced treatments.
4. Doctor’s Fees
Health insurance plans cover the consultation fees of doctors, specialists, nurses, etc.
5. Room Rent
This includes rent for regular wards or ICUs (Intensive Care Units). Some do not have a cap on room rent, allowing you to rent the best rooms.
6. Maternity or Newborn Cover
This includes all medical expenses incurred during pregnancy and delivery along with any treatment costs for the newborn baby for up to 90 days.
7. AYUSH
Some health insurance plans cover medical treatment through the AYUSH school of medicines, including Ayurveda, Yoga, Unani, Siddha and Homeopathy.
8. Medical Check-ups
Some policies offer free preventive health check-up facilities at regular intervals.
Also Read
Common Exclusions of Health Insurance Policies
- With the exception of a few health plans, most do not cover claims in the first 30 days of buying the policy.
- These cover pre-existing diseases only after a specific waiting period.
- Cosmetic procedures (plastic surgery, hormone replacement therapy, etc.)
- Dental treatment and eye surgery
- Self-inflicted injuries or suicide attempts
- Critical illness cover comes after a waiting period
- Injuries from adventure sports
- Injuries from war, terrorism or nuclear activity
- Sexually transmitted diseases like AIDS
- Non-medical expenses like service charges, toiletries, etc.
- Non-prescription drugs
The actual exclusions of your policy may vary depending on the insurer and health insurance terms and conditions. Make sure to read the fine print and know all the exclusions to avoid claims rejection during times of crisis.
Final Word
Choosing the right health insurance plan can be fairly difficult, but you can find the right one for you and your family with a little research. First, search and compare the health insurance terms and conditions of different plans to know which one offers the best coverage at affordable prices.
Navi offers a range of health insurance policies with coverage up to 1 Crore and premiums starting as low as Rs. 241 per month. Download the Navi App from the Play Store to get health insurance plans with comprehensive benefits.
FAQs
Ans: Yes. Even if you take good care of your health, unforeseen situations like a seasonal illness, accident or underlying medical conditions can affect anyone, anytime. Hence, it is advisable to have a health insurance policy to pay for expensive hospital bills.
Ans: There are two types of claims process for health insurance policies:
a. Cashless claims: The insured person avails treatment from a network hospital, and the insurer settles all bills directly with it.
b. Reimbursement claims: The insured person gets treatment from any hospital and files a claim for reimbursement with the insurer later.
Ans: Following are some of the documents you may need to furnish to buy a health policy:
• Identity proof
• Address proof
• Age proof
• Medical reports
• Passport size photo
Ans: Yes. Most health policies cover previously declared pre-existing conditions after a waiting period of around 2-4 years, depending on the insurer. So if you have medical conditions like diabetes, high blood pressure, kidney problems, etc., you should declare them before buying an insurance policy.
Ans: Yes. IRDAI has introduced two standard health insurance products- Corona Kavach and Corona Rakshak policy to cover medical expenses for treating Covid-19.
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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.
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