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The policy is meant to cover only the unexpected Hospitalisation Expenses and not any OR all medical expenses incurred.

The objective of the Policy is to cover Hospitalisation expenses for treatment of the ailment/injury requiring in-patient care wherein effective treatment would not have been possible on out-patient basis. If the admission of the patient is primarily for diagnostics and investigation and / or observation and evaluation, the Hospitalisation expenses are not reimbursed.

The policy is liable only to meet the expenses that are necessarily and reasonably incurred for treatment of the ailment.

There are certain expenses that are not admissible under the Health Insurance Policies, even though they would be necessary medical expenses. Please check the List of Non-admissible Expenses.

The Policy covers hospitalisation anywhere in India.

The minimum requirements for admissibility of the claim under your Health Insurance Policy are:

•  The person should have been covered under the Health Insurance Policy
• The hospitalisation should occur when the policy is valid / in force.
• Treatment for the ailment/injury cannot be done as an Out-Patient and requires admission as inpatient for a minimum period of 24 hours. Relaxation of minimum period of 24 hours is allowed for certain procedures or treatments like Cataract, Dialysis, Chemotherapy, etc. Please read your policy for the exact list of these procedures / treatments.
• Hospitalisation should be for curative purpose with active line of treatment and not for observation, evaluation or diagnostic purpose.
• Hospital should have been registered with the local authorities or it should meet the definition of a Hospital as described in the Policy with respect to number of beds, availability of Medical doctor & nursing staff round the clock, Operation Theatre, etc.
• The ailment or injury for which treatment is given does not fall under excluded diseases/conditions such as self inflicted injury, related to alcohol, congenital external conditions etc more specifically described in the Policy. Please refer to your policy for the list of exclusions.
• The line of Treatment should be proven and accepted and not experimental or unproven.

The above minimum requirements for admissibility of a claim are only indicative and not exhaustive.

Health insurance in India generally covers Allopathy, Ayurveda, Homeopathy and Unani systems of medicine. But specific policies may have special terms and conditions according to which claims would be admissible only for Allopathic system of medicine and alternative systems of medicine may not become payable . Health Insurance Policies do not cover treatments which are not approved or which are experimental in nature. Some of these are: Acupuncture/ Acupressure/ Ozone Therapy/ Music Therapy/ Magneto Therapy/ Electro Magneto Therapy/ RFQMR/ Hypnotherapy/ Naturopathy/ Aroma Therapy/ Baleno Therapy etc.

The expenses such as Room/ Bed Charges, Nursing Charges; Professional charges such as Consultant, Surgeon, Anesthetist etc; and expenses for investigations, diagnostics and Laboratory; Cost of implants like Stents, Intraocular lens, Pacemaker; Medicines, Drugs, Operation Theatre Charges, etc. are payable under the Health Insurance Policy.

Any other expenses not falling under any of the above headings are not payable like Telephone Charges, Service or Surcharges, Administrative charges, etc. Some of the policies list out the non-admissible expenses. You may visit our website for a comprehensive list of Non-admissible Expenses.

Limitation to the Admissible Expenses

The main limit in Health Insurance is the Sum Insured. Any medical expenses incurred over and above the Sum Insured will not be payable. However, if the policy is subject to ‘Cumulative Bonus’ the total policy limit shall be the Sum Insured + the Cumulative Bonus sum.

In addition to this, there may be various types of sub-limits depending on the type of policy:

• Sub-limits within a family floater for certain categories of beneficiaries. Ex. A Sum Insured sublimit of Rs. 100,000 for the parents within the family floater of Rs. 500,000. This means that parents can use only Rs. 100,000 although the overall family limit is defined as Rs. 500,000.
• Sub-limits for ailments/ procedures. Ex: Sub-limit of Rs. 50,000 for maternity claims; sublimit of Rs. 150,000 for cardiac ailment claims, sublimit of Rs. 32,000 for Appendicectomy, etc. All hospitalisation expenses admissible in respect of the condition/ ailment will be restricted to the specified limit during the policy period.
• Limit on the total liability of the Insurance in the event of a claim. Ex: The policy condition may say that the Insurance Company will be liable to pay only up to 80% of the Sum Insured. If Sum Insured is Rs. 100,000, the insurance company will pay claims only up to Rs. 80,000.
• Some of the Policies may have a cap on the Room Rent/ ICU Limit per day or prescribe a category of Room.
• Some of the policies may cap the other expenses like professional fee and other charges admissible to the eligible room category
• Some Policies may prescribe maximum amount allowable under Room/Profession Charges and other expenses at 25%, 25% & 50% of the Sum Insured respectively
• Some policies may have a Co-pay to be borne by the Insured like 10% Co-pay for all members of the family but 20% Co-pay for parents applicable on the admissible amount.
• Non-allopathic treatments may have a cap on the admissible amount. For Example, under New India policy for non-allopathic treatments like Ayurveda/ Homeopathy & Unani the limit is only 25% of the Sum Insured.

When one falls sick, one usually consults a family physician and gets relevant investigations done for proper diagnosis. The physician may initially prescribe certain medications/ administer some injections too. In spite of this treatment, the condition of the patient does not improve the physician advices the patient to get hospitalized for further management of the disease. Such medical expenses incurred before hospitalization are called Pre-Hospitalization Expenses.

During hospitalization, a major part of the treatment is complete but some part of the treatment extends beyond the hospitalization. It may involve follow-up visits to the doctor, medicines to be taken or follow-up investigations to be done. Such medical expenses are called Post-Hospitalization Expenses.

Pre-hospitalisation Expenses up to 30 days and Post-hospitalisation Expenses up to 30 or 60 days are generally payable under the Health Insurance Policy. However, there are some insurance policies wherein this period may be of a different duration.

Only those expenses relevant to the ailment for which the person has been hospitalized shall be considered under Pre & Post-hospitalisation Expenses head. Routine medications that the person would have been taking for the chronic ailment the patient had will be out of scope of this head.
 

If Health Insurance Policy is issued with a fixed sum insured against each individual insured person, the Policy is on ‘Individual Sum Insured’ Basis. Any claim beyond the Sum Insured set against the insured person is not payable for that person. However, if the policy is subject to ‘Cumulative Bonus’ the total policy limit shall be the Sum Insured + the Cumulative Bonus sum.

On the other hand if the Policy is issued with a consolidated Sum Insured for the entire family with no individual Sum Insured break-up for each member of the family, then policy is termed ‘Floater Sum Insured’ Policy. The Sum Insured floats over the members of the family and one claim or multiple claims by one member or more than one member of the family will be admissible up to the Floater Sum Insured limit during the policy period unless per claim sub-limit, beneficiary level sub-limit or ailment sub-limit is prescribed by the Health Insurance Policy.

Treatment or Surgical Procedures that can be conducted only in a hospital/ Nursing Home, where due to technological advancement the hospital stay is required to be less than 24 hours, are considered Day Care procedures. Cataract, Dialysis, and Lithotripsy are a few examples. The policies list out the Day Care Procedures. Check your policy for the list of covered Day-care Procedures. 

The treatment for illnesses/ diseases/ injuries which do not require admission as in-patient in the Hospital or nursing home and administered to the patient on out-patient basis in a clinic or hospital or nursing home fall under Domiciliary treatment. Most of the primary care treatments given in the clinic are considered as Domiciliary Treatment. Domiciliary Treatment is also called Out-patient Treatment. The expenses incurred for domiciliary treatment are not generally covered under Mediclaim Policies unless it is specifically mentioned. Please check your policy benefits for the coverage as well as the limits if any. 

Domiciliary Hospitalisation is not Domiciliary Treatment mentioned above. Some of the policies admit a claim under Domiciliary hospitalisation when the medical care and treatment for the disease/injury is taken at home but in the normal course would require care and treatment in the Hospital or Nursing Home only when

• The condition of the INSURED PERSON is such that he/she cannot be removed to the HOSPITAL / NURSING HOME; or
• The INSURED PERSON cannot be removed to HOSPITAL / NURSING HOME for the lack of accommodation therein;
• The period of treatment exceeding three days

It does not cover Pre and Post-hospitalisation expenses as well expenses for treatment for listed diseases such as Asthma; Bronchitis; Chronic Nephritis and Nephrotic Syndrome; Diarrhoea etc.

Health Insurance earlier entailed the complete settlement of the health care services bill by the individual to the hospital, followed by a reimbursement claim filed with the Insurance Company. The Insurance Regulatory Development Authority in India initiated the Cashless Hospitalization Process through Third Party Administration services for Health Insurance claims from 2002.

• Once you are covered under a Health Insurance Policy administered by us, you will be issued a Vidal Health Insurance TPA Pvt Ltd ID card. If your health insurance cover is issued through your employer, you may not be issued a physical ID card but you may have an E-card. This card will facilitate you to avail CASHLESS facility at the Networked Hospitals.
• Cashless hospitalization can be availed only at our network of hospitals. The essence of cashless hospitalization is that the insured individual need not make an upfront payment to the hospital at the time of admission
• Cashless is only a facility extended by the Third Party Administrators to the Insured persons through their Network of Hospitals who have agreed to certain terms and conditions.
• Cashless cannot be claimed as a matter of right and denial of a pre-authorization request is in no way to be construed as denial of treatment or denial of coverage or denial of your right to prefer reimbursement claim. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.
• If the policy covering you is subject to the GIPSA PPN arrangement, please check for the nearest hospital that is in the GIPSA PPN Package Agreement. Cashless facility for such policies will be available only in those hospitals who are under the GIPSA PPN Arrangement.

Process for availing Cashless Hospitalisation Facility

• Plan admissions only in such hospitals that are in our Network. If your policy is subject to GIPSA PPN Network, please get admitted only in such hospital that is in the GIPSA PPN Network. Your admission elsewhere will lead to denial of the cashless facility and even reimbursement of the expenses will be subject to the limits as per the GIPSA PPN Tariff.
• Produce the ID card issued by us at the Hospital Help Desk – along with any other ID Proof like DL/ Voter’s ID/ Passport etc in respect of THE PATIENT.
• Obtain the Pre-authorization Form from the Hospital Help Desk, complete the Patient Information and resubmit to the Hospital Help Desk
• Please indicate our ID Card Number without fail. In case the policy is taken by your employer you may also furnish the Employee Number.
• The Treating Doctor will complete the hospitalisation/ treatment information and the hospital will fill up expected cost of treatment
• This form is submitted to us either online or by fax
• We will process the request and call for additional documents/ clarifications if the information furnished is inadequate.
• Once all the details are furnished, we will process the request as per the terms and conditions as well as the exclusions therein and either approve or reject the request based on the merits of the case.

Once the request is received, it is processed. Our medical team will determine whether the condition requires admission and the treatment plan is covered by your Health Insurance Policy. They will also check with all the other terms and conditions of your Insurance Policy.

In case coverage is available, we will issue an approval to the hospital for a specified amount depending on the disease, treatment, sum insured available etc. This is sent by fax and e-mail (if available). The approval is called a “Pre-authorisation”. This pre-authorisation entitles you to avail the treatment at the hospital without paying for the medical expenses up to the authorised limit.

At the time of discharge, in case the amount authorized by us is not sufficient to cover the hospitalization expenses, the hospital will make a second/ final request on your behalf for sanction of additional amount. We will process this request and sanction will be made subject to terms and conditions of your health insurance policy.

Your policy may be subject to ‘Co-pay’. This is the compulsory amount that you need to bear in respect of each and every hospitalisation claim. Please check for this information. You are required to pay to the hospital the amount equal to the co-pay and obtain the necessary Bill & receipt. The hospital has to submit the proof for having collected this amount from you. If the hospital is not able to produce the requisite proof in respect of collection of co-pay from you, twice the amount of co-pay will be deducted as a penalty from the amount payable to the hospital.

Please verify your policy benefits to check your eligibility for Room Charges etc. An admission to a ward higher than your entitlement would cost your claim as the amount payable will be reduced in proportion the eligible ward charges bear to the higher ward charges billed.

Once final sanction has been received by the hospital, please make sure that you check and sign the original bills and Discharge Summary. Please carry home a copy of the signed bill and the Discharge Summary and all your investigation reports. This is for your reference and will also be useful during your future healthcare needs.

The hospital will ask you to pay for all the Non-admissible Expenses in your bill. You have to make this payment before discharge. You may check for the items disallowed against the List of Non-admissible Expenses in the website.

In case, for whatever reason, the pre-authorisation request cannot be approved, a letter denying preauthorization will be sent to the hospital. We may deny the Pre-authorisation without assigning any reason. In this case, you will have to settle the hospital bill in full by yourself.

Please note that denial of a Pre-authorization request is in no way to be construed as denial of treatment or denial of coverage. You can go ahead with the treatment, settle the hospital bills and submit the claim for a possible reimbursement.

Reimbursement of the hospitalization expenses can be claimed where Cashless Hospitalisation facility is not availed or treatment is availed in a Non-network Hospital. You will have to settle the hospital bill, collect all original hospitalisation documents and submit the documents to our office for their scrutinizing the same in terms of the policy and check the admissibility or otherwise of the claim/ expenses.

• Reimbursement claims may be filed in the following circumstances:
  

a. Hospitalization at a non-network hospital
b. Post-hospitalization and pre-hospitalisation expenses
c. Denial of preauthorisation on application for cashless facility at a network hospital

• Reimbursement claims can be submitted to us through registered post / courier or can be handed over at any of our Branches.

• One of the very basic requirements of insurance is ‘Claim Intimation’. It simply means intimating us or the Insurance Company about the hospitalisation. Some of the policies indicate a time frame of 24 hours or 7 days from the date of admission, most of the policies require that intimation has to be lodged immediately on admission. Non-compliance to this may make your claim inadmissible.

• The documents that you need to submit for a hospitalization reimbursement claim are:
  

a. Original hospital final bill
b. Pre-Numbered / Printed Receipts for payments made to the hospital
c. Complete break-up of the hospital bill
d. Original Detailed Discharge Summary
e. All Investigation reports
f. All medicine bills with relevant prescriptions
g. Operation Theatre Notes in the event of a surgery performed
h. Sticker for the Implant, if any, used during surgery
i. A copy of the Invoice for the implant, if any, used during surgery performed
j. Original duly completed and signed claim form
k. Duly completed and signed Medical Practitioner’s Form
l. Copy of our ID card or current policy copy and previous years’ policy copies if any
m. Company Employee ID card if you and your family are insured through your employer
n. Documents for National Electronic Fund Transfer (NEFT)
  i.  NEFT Format giving details of the Bank Account where you need the claim amount to be transferred
                ii. A copy of the page of the Bank Pass Book containing the Account Number & the Name/ Address of the Account Holder
                iii. A cancelled Cheque for the above Account in to which the claim amount has to be transferred
o. Covering letter stating your complete current address, contact numbers, email ID if available and the list of documents attached.

• The documents that you need to submit for a Post-hospitalization or a Pre-hospitalization claim are:

a. Copy of the discharge summary of the corresponding hospitalization
b. All relevant doctors’ prescriptions for investigations and medication
c. All bills for investigations done with the respective reports
d. All bills for medicines supported by relevant prescriptions
e. NEFT Documents as above. (If you have furnished the NEFT Documents for the main hospitalisation claim earlier, you may indicate that the amount be transferred to the same Bank Account.)

• Once the reimbursement claim is received, it is processed. Our medical team will determine whether the condition requiring admission and the treatment are covered by your health insurance policy. They will also check with all the other terms and conditions of your insurance policy. All Non-admissible Expenses will be disallowed.

• The policies stipulate a period from the Date of Discharge within which the claim documents have to be submitted. Submission of claim papers after the stipulated period could lead to denial of the claim. Normally it is 7 days from the date of discharge for hospitalisation claim and for Post-hospitalisation it is 7 days from the date of completion of the post-hospitalisation treatment. Please check for the time frame for submission of the claim papers. In case the claim papers are submitted beyond 7 days from the date of discharge the claim is liable to be denied as per the policy terms. Hence, ensure compliance to the time frame without fail.

• Based on the processing of the claim, a denial or approval is executed. In case of approval, settlement is made by transferring the approved amount to your Bank Account. We will also send you the settlement particulars along with the computation sheet to the address mentioned in your health insurance policy. In case you have been insured through your Company, the cheque will be dispatched based on instructions received from your company.

• In case we require additional documents we may send you a Shortfall Letter. Kindly comply with the requirements within the stipulated time. In case you do not submit the required documents within the stipulated time, after 2 reminders we will reject the claim and send the Denial Letter. Once the claim is denied as above, you will forfeit your right to the claim.

• In case your claim is denied, the denial letter is sent to you by courier / post quoting the reason for denial of your claim. In case you have been insured through your Company, the denial letter will be dispatched based on instructions received from your company.

• In the event you are aggrieved with the settlement or the denial of the claim, you may kindly represent your case to our Grievance Cell. You may also refer the matter to your Insurer’s Grievance Cell.

• If you are not satisfied with the redressal of your grievance either through our Grievance Cell or that of the Insurer, you may present your case before the Insurance Ombudsman.
  

Network Hospitals

Any hospital that has entered into an agreement with us to provide Cashless facility for our card-holders is called a Network Hospital. You can check at our website or call our Call Centre to check whether a specific hospital is in the List of our Network Hospitals. Please furnish the name of your Insurer &/or the name of your Corporate in case you are covered by your employer to advise you properly.

Apart from our general Network of Hospitals, there may be subsets of this Network such as Preferred Provider Network, restricted network, insurer specific network, etc. based on terms and conditions of different insurance policies / products. The list of Network Hospitals is a dynamic list and therefore the latest may be verified at our Website.

Restricted Network

In some policies, policy holder / insured is not allowed to avail cashless facility at all our network hospitals. Within the general network, only specific hospitals are available for the policy holder to avail cashless facility. This is called Restricted Network. If the policy holder /insured wishes to avail treatment in any of the other network hospitals, he cannot avail cashless facility, but instead, will have to apply for reimbursement after settling the hospital bills himself / herself. 

Preferred Provider Network

In some policies, where there is co-payment, there may be some hospitals where this co-payment is not applicable. These are called Preferred Provider Network hospitals. Such hospitals generally have a reasonable tariff rate agreement with us for common procedures. 

GIPSA Network

The Public Sector Insurers viz National Insurance Co Ltd., New India Assurance Company Ltd, Oriental Insurance Co Ltd & United India Insurance Co Ltd have negotiated special package rates for a good number of procedures commonly undergone from many hospitals across India. Cashless facility for those procedures is available only in the GIPSA Network Hospitals. Claim for treatment taken elsewhere will have to be submitted for reimbursement.

This happens when you have ample time to plan your admission to the hospital. For example, if the doctor advises surgery for hernia and says that you can undergo the surgery anytime in this month, it gives you time to plan your surgery.

In such cases, it is prudent to send the preauthorization request to Vidal Health Insurance TPA Pvt. Ltd. at least 72 hours before your planned admission. This will ensure a hassle-free admission procedure for you at the hospital.
 

This happens typically in case of emergencies such as a road traffic accident or in an acute condition like Acute Gastro Enteritis/ Acute Appendicitis etc. There is no planning involved in the hospitalization. In such situations the Vidal Health Insurance TPA Pvt. Ltd. ID card can be shown at the network hospital to avail cashless admission facility. The preauthorization request can be sent to the Vidal Health Insurance TPA Pvt. Ltd. within four hours after admission.

It is, therefore, prudent that every insured individual should carry their Vidal Health Insurance TPA Pvt. Ltd. ID card with them at all times. You can never predict an emergency!
 

Health Insurance Policy is meant to cover unexpected, reasonable and necessary/customary Medical expenses of Hospitalization either due to an illness or injury which, in the normal course, requires treatment as In-patient for a minimum period of 24 hours in a Hospital/Nursing Home.

The policy seeks to meet the hospitalisation expenses required by a person in the normal course. Though in many cases hospitalisation is a requirement, the Insurers would not cover them as they are either not required by the public in general or would not amount to insurance or would require a higher premium to cover the risk- hence, the concept of exclusions. Exclusions define those procedures / ailments that will not be covered by the Health Insurance Policy.

The Exclusions are imposed in the policy in order to:

• Restrict cover to normal risks required by average insured
• Exclude losses of extra-ordinary/ catastrophic nature
• Define & clarify scope of cover
• Exclude risks which require additional inputs
• Exclude risks of frequent nature
• Exclude intentional losses 
• Exclude inevitable losses
• Exclude commercially un-insurable

Common Exclusions in Health Insurance Policies

The general exclusions that are found in most health insurance polices in India are listed below. Please do read your policy document to know the exact list of exclusion applicable to you:

• Pre-existing diseases
• Any illness in contracted during the first 30 days except accidents
• First year/ Two Years /Four Years exclusions for certain ailments
• Preventive Medical Expenses like Vaccination, Inoculation etc.
• Cosmetic, aesthetic treatment
• Circumcision, Change of Life
• Plastic surgery unless due to accident or part of treatment of an ailment
• Congenital External diseases/conditions
• Treatment for Sterility, Infertility, Assisted Conception
• Venereal Diseases, Sexually Transmitted Diseases
• Intentional self injury, Suicide, Psychiatric/Psychosomatic Disorders, Alcohol or drug misuse or abuse.
• Surgery for correction of eye sight, cost of contact lens, spectacles, hearing aids, CPAP and other durable medical equipments.
• Dental treatment unless arising out of an accident and unless the treatment requires inpatient admission.
• HIV, AIDS and related conditions.
• Genetic Disorders
• Stem Cell Treatment
• Injuries sustained whilst being engaged in a Hazardous Activity or Hazardous Sports
• Hospitalisation primarily for Diagnostic/evaluation purposes without active line of treatment during hospitalisation.
• Medical Expenses for illness or injuries which are treated on an Out Patient basis.
• Mere Hospitalisation of 24 hours or more does not guarantee admissibility of the claim. Any treatment or procedure usually done in OPD ,even if converted to Day care Surgery procedure or as inpatient in Hospital for more than 24 hours, will not be payable.
• If expenses are unreasonable and unnecessary, the claim is likely to be rejected.
• Medical Expenses incurred in a Hospital or Nursing Home not meeting the criteria as defined will be outside the scope of cover. Check with the Hospital whether it meets the criteria before Hospitalisation.

The above list is indicative and not exhaustive. Exclusions may differ from policy to policy and Insurer to Insurer.

We are all concerned about “Health” - our own, and that of our dear & near ones. Not all are blessed with perfect health. We do suffer from sickness and meet with accidents in spite of taking all steps, precautions, preventions. A majority of our ailments are minor and seasonal. They are either cured on their own or require very little medical intervention. A few of them, however, require treatment in Hospitals or Nursing Homes as In-patients and we should use our health insurance cover only then.

• Use the Health Insurance benefit only for yourself or your covered dependents. Using your Health Insurance for anyone not covered is tantamount to financial misappropriation – you may find that your Health Insurance cover is exhausted when you actually need it.

• Act as a prudent insured at all times – please do not treat your insurance benefit as if it were your debit card. Do not use Health Insurance for trivial reasons.

• Use your Health Insurance cover only when you really need it – do not waste it on minor ailments that can very well be treated as an outpatient.

• Meet the doctor of your choice and seek opinion on the treatment line. It is always beneficial to take a second opinion when major treatment such as surgery has been suggested.

• Enquire about the cost of the procedure and quality of service in various places before you decide on your hospital of choice. Remember that ‘expensive’ is not always directly proportional to ‘quality’. In healthcare, there are a whole lot of  small hospitals doing quality work. A number of procedures also do not require hospitalisation even for a day – there are a good number of day care Centers carrying out these surgeries. You can save on the cost of hospitalisation as well as save the trouble of being in the hospital unnecessarily.

• Avoid admission to luxury category rooms/ wards – All the expenses – not only the room charges but all other expenses go northwards. Health Insurance is for necessary and reasonable treatment and not for enjoying luxuries!

• Always keep in mind that the more you use your Health Insurance cover today, the higher will be the premium you have to pay to remain covered tomorrow – Health Insurance cost can become prohibitive and unaffordable for you / your Employer. This is a point worth pondering on!

The pattern of disease is shifting from a world of communicable & infectious diseases to a world of non-communicable & life-style diseases. This has created a great long term burden on the cost of healthcare. The only thing that will help is prevention and management. Non-communicable and life-style diseases are cancer, arthritis, cardiac ailments, diabetes, hypertension, obesity, etc. A whole lot of these can be prevented by judicious changes in lifestyle and a lot others can be managed, again, by lifestyle changes. It must be remembered that these diseases, unlike communicable / infectious diseases will be with us for a lifetime and can make the quality of life miserable.
Some lifestyle changes that all of us can work on:
• Regular exercise – yoga, aerobics, jogging, swimming, etc.
• Balanced diet – avoid junk foods
• Avoid smoking, excessive alcohol, drugs
• Mental relaxation techniques such as meditation
• Laughter – the best medicine
• Regular health checks to catch them early
The list is endless – we know about these – but doing is what matters!

Certain Health Insurance policies may define limits that can be paid out for certain named procedures. Any amount over and above the defined benefits will have to be borne by the policy holder / insured. For ex. if the policy defines that the defined benefit / cap for cataract is Rs. 20,000, the maximum claim settlement value for cataract claim will be Rs. 20,000 although the sum insured may be any amount.

One of the very basic requirements of insurance is called ‘Claim Intimation’. It simply means intimating the TPA or the Insurance Company that a claim is going to be made in the near future. Some of the policies indicate a time frame of 24 hours or 7 days from the date of admission, most of the policies require that intimation has to be lodged immediately on admission. Non-compliance to this may make your claim inadmissible.

Studies have shown that a majority of the hospitalizations are planned hospitalizations. Therefore, the insured is in a position to give Advance Claim intimation. This has several advantages:

• The TPA gains prior knowledge that a claim is in the pipeline
• The TPA can prepare itself in advance to process your claim
• The TPA can arrange to get any information, from the Insurance Company, that it may be required to process your claim, thus preventing delay in processing after you submit the documents.
• The TPA can help negotiate appropriate rates for your treatment at the hospital.
• The TPA can intimate you in advance about the admissibility of the claim, so that you can prepare yourself for the financial burden that you face.

Claim intimation generally requires the following information to be provided:
• Nature of illness / injury (can be in your own words)
• Nature of treatment (can be in your own words)
• Hospital name and location
• Probable date of admission and expected length of stay in the hospital
• Name of the treating doctor / Consultant

A hospital / nursing home is an institution in India established for indoor care and treatment of sickness and injuries. The hospital or nursing home should be registered with the appropriate local authority and it should be functioning under the supervision of a registered and qualified medical practitioner. If not, it should satisfy the following criteria:
• It should have at least a minimum of 15 inpatient beds (10 beds in C class towns)
• It should have fully equipped operation theatre in case surgeries are being carried out
• It should have fully qualified nursing staff under its employment round the clock
• Fully qualified doctors should be available round the clock.

A place of rest, a place for the aged, a place for substance abuse rehabilitation, a hotel, etc. that may be termed as ‘hospital / nursing home’ does not fall under the health insurance definition of hospital / nursing home.
 

• Benefit Policies: In case of multiple policies which provide fixed benefits, a policy holder can claim in one or more policies and the insurer will make a claim payment irrespective of the payments received under other similar policies.
• Indemnity Policies : In case of multiple policies that indemnify health expenses, if there is a claim, the policyholder will have the right to choose an insurer for lodging the claim and irrespective of the fact whether other policies are in place, insurer must pay the claim as long it is falling within its terms and conditions. If there are amounts that are disallowed under the earlier chosen policy, then the insured can claim those amounts from another policy and the insurer is liable to settle this claim as per the terms and conditions of this policy.