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.
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.
The individual, group, or organisation who has obtained some sort of coverage through an insurance policy.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Newborn baby refers to a baby born during the policy period and is aged up to 90 days.
Ambulance expenses refers to the cost of transportation of the insured person for medical emergencies.
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.
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.
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.