Employee Insurance Glossary

A-Z coverage of group health insurance policies

Categories

Group Health Insurance

Group Health Insurance

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Covid Insurance

Covid Insurance

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Super Top-Ups

Super Top-Ups

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AYUSH Hospital

An AYUSH Hospital is a healthcare facility wherein treatment procedures, and interventions are carried out by AYUSH medical practitioners.

AYUSH Hospital

AYUSH Treatment

This refers to hospitalisation treatments given under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.

AYUSH Treatment

Accident

This refers to a sudden, unforeseen and involuntary event caused by external, visible and violent means.

Accident

Aggregate Deductible

An aggregate deductible is the amount a policyholder would be required to pay on claims during a given period of time.

Aggregate Deductible

Ambulance Expenses

Ambulance expenses refers to the cost of transportation of the insured person for medical emergencies.

Ambulance Expenses

Cancellation

The terms on which the policy contract can be terminated either by the insurer or the insured by giving sufficient notice to the other within a specified period of time.

Cancellation

Cash Deposit (CD) Account

Cash Deposit (CD) accounts are created for a company with its insurer for the purpose of insurance-related transactions. It is a non-interest-bearing account, with all the premium payments made by the company being deposited into this account.

Maintaining a cd balance in insurance has the advantage of instantly adding employees to the corporate policy by paying the premium out of the CD account.

Cash Deposit (CD) Account

Cash Deposit (CD) Balance

Cash Deposit (CD) balance in insurance refers to the balance maintained by an employer in the company's CD account so as to easily add new employees to the corporate health policy as soon as they join the company.

Cash Deposit (CD) Balance

Cashless Claims

In the case of cashless claims, insurance companies pay directly to the hospital. There is no waiting period for reimbursement. This means the policyholders can get medical treatment at a network hospital without paying from their pocket at the time of hospitalisation.

Cashless Claims

Co-Pay

Health insurance co-pay refers to an arrangement in which the policyholder will need to pay a portion of the medical expenses on their own and the insurance company will pay the remaining amount. This is usually covered under the portion of the co-pay clause of any policy. Having co-pay means lower premiums but also has the drawback of a bad employee claims experience.

Co-Pay

Co-payment

Co-pay refers to an arrangement in which the policyholder will need to pay a portion of the medical expenses on their own and the insurance company will pay the remaining amount. This is usually covered under the portion of the co-pay clause of any policy. A co-payment does not reduce the sum insured.

Co-payment

Corporate Floater

A corporate floater or corporate buffer plan is a common pool of coverage maintained at an organisation level by the employer. This coverage can be availed during emergencies by any of the employees once they have exhausted their individual policy.

Corporate Floater

Covid Hospitalisation Cover

The insurer shall compensate medical expenses incurred for hospitalisation of the policyholder during the policy period for the treatment of Covid on a positive diagnosis of the virus in a government-authorised diagnostic centre. This includes expenses incurred on treatment for Covid up to the sum insured specified in the policy.

Covid Hospitalisation Cover

Day-Care Treatment

Day-care treatments are procedures that require hospitalisation for less than 24 hours. Insurance policies may or may not provide coverage for such treatments depending on the policy type.

Day-Care Treatment

Deductibles

A deductible is a proportion of the medical expenses the policyholder must pay out of their pocket before they can raise an insurance claim. The insurance company will pay the claim amount directly to the policyholder or the hospital only when the deductible amount is paid.

Deductibles

Dependents

A dependent refers to a person who is covered under another individual’s insurance plan. Any family member who is added to your health insurance plan is considered to be a dependent.

Dependents

Disclosure To Information Norm

A policy shall be void in the event of non-disclosure of any medical information by the policyholder.

Disclosure To Information Norm

Domiciliary Expenses

Refers to expenses incurred for an illness/injury that would have led to hospitalisation but is being treated at home due to unavailability of hospital rooms or because the patient cannot be moved to the hospital in their current condition. The insurance company will only offer reimbursement for such expenses up to the limit stated in the policy.

Domiciliary Expenses

Emergency Care

Emergency care is for an illness with symptoms which occur suddenly and unexpectedly. Such ailments require immediate care by a medical practitioner to prevent death or serious long-term health issues for the insured person.

Emergency Care

Employer-Employee Insurance

Employer-Employee Insurance is simply a scheme in which a company provides life, medical or personal accident group insurance for its employees and their families. The employer pays the premiums on this insurance plan, but the beneficiary is the employee and their dependents. It is deductible from the employee’s CTC and is presented as a workplace benefit by companies.

Employer-Employee Insurance

Endorsements

Endorsements are the activity of adding, removing or correcting details of members of a company from the Nova Portal and with the insurer so that all information pertaining to the company's group health insurance is always updated.

An insurance endorsement is a mini-policy that is added to a current insurance policy to change certain information on the original insurance documents. It helps to enhance the insurance policy and update details for coverage of policyholders.

Endorsements

Exclusions

Exclusions refer to treatments for which the insurance company does not provide coverage. So, claims against such treatments will be rejected by the insurance company.

Intentional injuries, congenital diseases and HIV are a few examples of exclusions in health coverage. The list of exclusions can be different for different insurers and even for different policies provided by the same insurer. This is why it is important to have all the information regarding your policy to avoid sudden surprises in an emergency.

Exclusions

Grace Period

It refers to the period of time immediately following  the premium due date during which a payment can be made to renew or continue a policy without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases.

Grace Period

Health Care Worker

Health care worker refers to doctors, nurses, midwives, dental practitioners and other health professionals, including laboratory assistants, pharmacists, physiotherapists, technicians and people working in hospitals.

Health Care Worker

ICU Charge

This refers to covering the charges of being admitted to the Intensive Care Unit. Many insurance policies also have a limit on the extent to which they cover ICU charges.

ICU Charge

In-Patient Care

This means treatment for which the policyholder has to stay in a hospital for more than 24 hours to avail insurance coverage.

In-Patient Care

Insured

The individual, group, or organisation who has obtained some sort of coverage through an insurance policy.

Insured

Insurer

Insurer refers to the entity that provides you with an insurance policy. It is an organisation that provides you with necessary financial coverage based on the insurance policy sold by them.

Insurer

Maternity Coverage

Medical expenses traceable to childbirth (including complicated deliveries and cesarean sections incurred during hospitalisation), and expenses towards lawful termination of pregnancy are covered under the maternity clause of health insurance.

Maternity Coverage

Members Covered

This refers to the extent (number of members) to which your insurance provides coverage. Family members might include - a spouse, dependent children, and dependent parents.

Members Covered

Natal Expenses

Pre-natal and post-natal expenses refer to costs pertaining to ultrasound, regular checkups, doctor's consultation fee, medicines and so on. It includes expenses incurred owing to pre & post delivery medical care for a mother.

Natal Expenses

Network and Non-Network Hospitals

Any hospital that has an agreement with an insurance company for providing cashless treatment is referred to as a network hospital. On the other hand, hospitals that are not a part of the network of an insurance company are called non-network hospitals.

Network and Non-Network Hospitals

Newborn Baby

Newborn baby refers to a baby born during the policy period and is aged up to 90 days.

Newborn Baby

Portability

This refers to the transfer by a policyholder (including family cover) of the credit gained for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.

Portability

Post-Hospitalisation Medical Expenses

Relevant medical expenses incurred up to a certain period of time (depending on the policy type) after hospitalisation will be covered by the health insurance. This includes expenses such as doctor follow-ups, medical tests, and medications.

Post-Hospitalisation Medical Expenses

Pre- Hospitalisation Medical Expenses

Relevant medical expenses incurred up to a certain period of time (depending upon the policy type) before hospitalisation will be covered by the health insurance. This includes expenses such as doctor follow-ups, medical tests, and medications.

Pre- Hospitalisation Medical Expenses

Pre-Existing Covered

This refers to the question of if the policy will cover the expenses for the treatment of pre-existing diseases of the policyholder. Pre-existing diseases refer to ailments an individual is diagnosed with before or while buying health insurance. The group health insurance offered by Nova covers pre-existing diseases of employees from day 1 if any.

Pre-Existing Covered

Reimbursement Claims

Reimbursement claims are raised when you get treated in a non-network hospital or when you decide to not opt for cashless benefits in your health plan.  In such cases, the policyholder pays for the medical expenses out of their pocket and then files a reimbursement claim for the same.

Reimbursement Claims

Room Rent Limit

The limit imposed on the coverage of boarding expenses at the hospital or room rent of the hospital is called the room rent limit. The limit is either expressed as an absolute amount or as a percentage of the sum insured. Often times a company offers a high sum-insured of say ₹7-10L but the room rent limits would be capped at ₹3,000. This defeats the whole purpose of taking a higher sum-insured. When your room-rent limit is capped at ₹3,000 any expenses in hospital rooms with a higher per-day rent will also be capped at 3,000 no matter what your sum-insured is.

Room Rent Limit

Sum Insured

The sum insured is the maximum value for a particular year that the insurance company can pay if you are hospitalised. Any amount exceeding the sum insured will have to be borne by the policyholder. The amount you agree on for the sum insured will be the maximum amount you get in case of hospitalisation or medical procedures.

Sum Insured

TPA

A Third Party Administrator (TPA) is an intermediary between the insurance provider and the policyholder. Its key function is to ensure the settlement/processing of insurance claims.

TPA

The Validity Of The Insurance Policy

Health insurance claims are only applicable if your health plan is valid. If your health policy has expired then your claim will be rejected by the insurance company. So, to avoid any inconvenience during an emergency, you must ensure that your insurance policy is correctly updated.

The Validity Of The Insurance Policy

Unproven Treatments

Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their requirement. However, treatment authorised by the government for the treatment of COVID is always covered.

Unproven Treatments

Waiting Period

This refers to the time period before a selected list of ailments begins to get covered by your policy. Usually, this applies to pre-existing ailments, and some ailments may have a waiting period of a year or two.

Waiting Period

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