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.
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.
The individual, group, or organisation who has obtained some sort of coverage through an insurance policy.
This refers to a sudden, unforeseen and involuntary event caused by external, visible and violent means.
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.
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.
An aggregate deductible is the amount a policyholder would be required to pay on claims during a given period of time.
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.
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.
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.
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.
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.
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.