Health Insurance FAQ | Medical Insurance FAQ

Health Insurance FAQs

Do I need Health insurance?
As per the studies the health care cost is rising exponentially. And health insurance is a measure to avoid paying out such huge medical bills out of the pocket in unexpected situations like illness or medical treatment. It is advisable to have an adequate coverage to reduce the risk of financial difficulties.

How is Health insurance affected by my age?
When you grow older you are more prone to illness or disorders. Thus the cost of the insurance rises as per the age.

If a claim is made for a particular ailment, does it become a pre-existing disease for the next policy term?
An ailment for which a claim has already been made does not become a pre-existent disease if there is no break in the term of the insurance policy and is renewed by the due date. However, the ailment becomes a pre-existent disease and exclusions will apply in the event if there is a break in the term of insurance. A break of maximum 7 days is allowed under certain conditions, though it varies by company.

How are hospital defined with regards to the health insurance policies?
Any institution established for indoor care and treatment of sickness and/or injuries, which is duly registered and supervised actively by a registered medical practitioner.
OR
Any establishment that satisfies the following criteria can qualify as a hospital, has at least 15 patient beds, fully equipped operation theater of its own if surgical procedures need to be carried out, employs qualified nursing staff and has qualified doctors in charge around the clock. Ayurvedic or institutions practicing alternative medicine therapy also qualify as hospitals.

What is meant by hospitalization?
An instance where the insured individual is hospitalized for a minimum period of 24 hours can be termed as hospitalization. Specific treatments like dialysis, chemotherapy, radiotherapy, laser eye surgery, dental surgery, etc when the patient is discharged on the same day are also considered hospitalization.

What is 'Any one illness' with reference to health insurance policies?
'Any one illness' would mean the continuous period of illness, including relapse within 45 days from the last consultation with the hospital where the treatment was taken.

Can I claim medical expenses incurred before and after a surgery?
You can claim medical expenses incurred 30 days before and 60 days to 90 days after hospitalization, provided they are related to the ailment/accident for which you were hospitalized. Such expenses are termed as pre and post hospitalization. Different insurers treat this differently, hence please check the exclusions and inclusions in the policies. To make matters simple for you, PolicyBazaar compares the features of various policies side by side, making it easier for you to choose the best suitable policy.

Will medical costs be reimbursed from day one of the cover?
Typically, there is a waiting period of 30 days, within which no claims by the insured are entertained by the insurer. This waiting period may vary by company.
Are there limits to the number of claims on a Health Insurance Plan?
There is no limit to the number of claims per annum but there is a limit to the amount you can claim in a year. Usually, the maximum amount you can claim in a year is limited to the sum insured. However, special plans that provide surgical benefits and daily hospitalization cash allowance have restrictions on the amount you can claim per annum.

Can I make claims for expenses incurred at home and not in hospital?
Yes, you can but there are certain conditions. Such claims are entertained only if the condition of the patient is such that she/he cannot be moved to the hospital or no bed is available. Furthermore, treatment must be provided comparable to that at a hospital or a nursing home. Such claims are known as domiciliary hospitalizations.

Can I use the same health insurance policy from Mumbai to make a claim if I am in Delhi?
Yes, your health insurance policy is valid all over the country.

Can I claim expenses incurred for my mother's cataract operation in the first year of buying the policy?
No, you cannot claim expenses for a cataract operation in the first year of the policy. Most insurers have a set of specific illnesses or ailments for which they will not provide cover in the first two years from the commencement of policy; however these are covered from third or fourth year onwards.

What happens when I make a claim on a Critical Illness Plan? Does the policy still continue?
Usually, the policy would cease in the event of a claim. However, certain insurance plans offer to cover the insured for the remaining critical illnesses, at a lower sum assured and a revised insurance premium.

If an individual is already suffering from a disease, will the health insurance plan still reimburse his or her expenses related to the disease?
A health insurance policy would not cover a pre-existing disease in the first year of cover. However, they would be covered after three to four years of continuous renewal.

Will my claims be reimbursed even if I do not get myself treated at a network hospital?
Yes insurance companies reimburse expenses even if the insured does not use the network hospital.

Will I get a discount at the time of renewal if I do not file any claim during that year?
Yes you will get a bonus for each claim free year. The sum insured increases progressively in respect of each claim free year of insurance, subject to a maximum accumulation of 10 claim-free years. In the event of a claim, if the insured has earned any cumulative bonus, the increased sum insured will be reduced by a fixed per cent at the time of renewal.

Free medical check up
The insured is entitled to reimbursement of medical check-up once at the end of a block of every four or five claim-free years. The reimbursable cost is typically restricted as a proportion of the average sum insured during the block of four or five years.

Is there a time limit for stay in the hospital under the health insurance plan?
Typically, the insured can make a claim if her/his hospitalized stay is for over 24 hours. However, for certain treatments the stay could be shorter.

What happens when the limit is exhausted under a Health Insurance Policy?
If the insurance limit i.e. the sum insured is exhausted in a particular year due to large medical expenses, the insurer is not liable to bear or reimburse the insured for any further expenses.

Who will receive the claim amount if the insured dies at the time of treatment?
The claim amount is paid to the nominee of the insured. If no nominee is assigned, the insurance company will insist upon a succession certificate from a court of law for disbursing the claim amount.

What is the procedure for availing cashless facility?
In case of planned hospitalization, insurers require the first prescription with the details of the case history indicating:

Provisional diagnosis or reason for getting admitted in the hospital
Proposed date of admission
Approximate expenses
Name of the hospital and consultants
Approximate duration of stay at the hospital
Attached doctor's prescription with admission note

The above documents are to be delivered to the insurer at least 72 hours before admission. The procedure could vary by company therefore it is important to refer the policy details carefully. If I avail of cashless facility, will the insurance company pay the entire bill at the hospital? No, a part of the bill is borne by the insured if it consists of the inadmissible amounts that are listed by the insurer. What happens in an Emergency hospitalization where Cashless facility is not authorized? The liability to pay the hospital bills will be on you. However, insurer will reimburse the admissible amount.

What is a No Claim Discount?
Is a discount on the Basic Premium if there is a claim free year of the policy. If the insured does not make any claim, then he gets a discount on certain percentage on basic Premium for every claim free year.

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