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A Health Insurance Policy would normally cover expenses reasonably and necessarily incurred under the following heads in respect of each insured person subject to the overall ceiling of the sum insured (for all claims during one policy period).

a. Room, Boarding expenses
b. Nursing expenses
c. Fees of surgeon, anesthetist, physician, consultants, specialists
d. Anesthesia, blood, oxygen, operation theatre charges, surgical appliances, medicines, drugs, diagnostic materials,
    X-ray, Dialysis, chemotherapy, Radiotherapy, Cost of a pacemaker, Artificial limbs, cost, or organs, and similar expenses.

Sum Insured
The Sum Insured offered may be on an individual basis or on a floater basis for the family as a whole.

Cumulative Bonus (CB)
Health Insurance policies may offer Cumulative Bonus wherein for every claim-free year, the Sum Insured is increased by a certain percentage at the time of renewal subject to a maximum percentage (generally 50%). In case of a claim, CB will be reduced by 10% at the next renewal.

Cost of Health Check-up
Health policies may also contain a provision for reimbursement of the cost of health check-up. Read your policy carefully to understand what is allowed.

The minimum period of stay in Hospital
In order to become eligible to make a claim under the policy, minimum stay in the Hospital is necessary for a certain number of hours. Usually, this is 24 hours. This time limit may not apply for the treatment of accidental injuries and for certain specified treatments. Read the policy provision to understand the details.

Pre and post hospitalization expenses
Expenses incurred during a certain number of days prior to hospitalization and post hospitalization expenses for a specified period from the date of discharge may be considered as part of the claim provided the expenses relate to the disease/sickness. Go through the specific provision in this regard.

Cashless Facility
Insurance companies have tie-up arrangements with a network of hospitals in the country. If policyholder takes treatment in any of the network hospitals, there is no need for the insured person to pay hospital bills. The Insurance Company, through its Third Party Administrator (TPA), will arrange direct payment to the Hospital. Expenses beyond sub limits prescribed by the policy or items not covered under the policy have to be settled by the insured direct to the Hospital. The insured can take treatment in a non-listed hospital in which case he has to pay the bills first and then seek reimbursement from Insurance Co. There will be no cashless facility applicable here.

Additional Benefits and other stand-alone policies
Insurance companies offer various other benefits as “Add-ons” or riders. There are also stand-alone policies that are designed to give benefits like “Hospital Cash”, “Critical Illness Benefits”, “Surgical Expense Benefits” etc. These policies can either be taken separately or in addition to the hospitalization policy.

A few companies have come out with products in the nature of Top Up policies to meet the actual expenses over and above the limit available in the basic health policy.

Exclusions
The following are generally excluded under health policies:

1. All pre-existing diseases (the pre-existing disease exclusion is uniformly defined by all non-life and health insurance companies).
2. Under the first-year policy, any claim during the first 30 days from date of cover, for sickness/disease. This is not applicable for accidental injury claims.
3. During the first year of cover – cataract, Benign prostatic hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in the anus, piles, sinusitis, and related disorders.
4. Circumcision unless for treatment of a disease
5. Cost of specs, contact lenses, hearing aids
6. Dental treatment/surgery unless requiring hospitalization
7. Convalescence, general debility, congenital external defects, V.D., intentional self-injury, use of intoxicating drugs/alcohol, AIDS, Expenses for Diagnosis, X-ray or lab tests not consistent with the disease requiring hospitalization.
8. Treatment relating to pregnancy or childbirth including cesarean section
9. Naturopathy treatment.

The actual exclusions may vary from product to product and company to company. In group policies, it may be possible to waive/delete the exclusions on payment of extra premium.
No short period policies
Health insurance policies are not issued for less than one year period.

Insurance Intermediaries

• Insurance is a complex product representing a promise to compensate the insured or third party according to specified terms and conditions in the event of the occurrence of a covered contingency. In most insurance transactions there is usually an intermediary - an insurance agent (individual or corporate) or an insurance broker.
• Insurance intermediaries serve as a bridge between consumers (seeking to buy insurance policies) and insurance companies (seeking to sell those policies).
• Insurance brokers are licensed by the IRDAI and governed by the Insurance Regulatory and Development Authority (Insurance Brokers) Regulations, 2002. Individual insurance agents and corporate agents are also licensed by the IRDAI and governed by the Insurance Regulatory and Development Authority (licensing of Individual Insurance Agents) Regulations, 2000 and the Insurance Regulatory and Development Authority (Licensing of Corporate Agents) Regulations, 2002, respectively. These Regulations lay down the Code of Conduct for the respective intermediaries.
• An intermediary has a distinct role to play in the entire life cycle of a product, from the point of sale through policy servicing, up to claim servicing. An intermediary shall provide all material information with respect to a proposed cover to enable the prospect to decide on the best one. The intermediary is expected to advise the prospect with complete disclosures and transparency.. After the sale is effected, the intermediary must coordinate effectively between the customer and the insurer for policy servicing as well as claim servicing.
• IRDAI has prescribed regulations for protecting the interests of policyholders casting obligations not only on Insurers but also Intermediaries. These prescribe obligations at the point of sale as well as policy servicing and claims servicing.
  
  

Tips on Dealing with Insurance Intermediaries

• While dealing with Insurance Intermediaries, check out the following:
• Ask for and check whether the person holds a valid license and is authorized for the particular business. For example, the Intermediary should be licensed to sell life insurance or general insurance or both (holding a composite license). A referral always helps.
• Check whether he or she has a good knowledge of various insurance products/policies
• He or she should understand your needs and what you are seeking. Always ensure that you consider only products that you can afford. Beware of tall promises and over-selling tactics. Consider only what you can afford.
• Ask questions and understand the policy terms and conditions of the policy the Intermediary is trying to explain to you.
• You must be satisfied that you understand what your commitments are. What are the payments or amounts that you have to bear not only when you take the policy but when you surrender it or when you make a claim.
• Ask for brochures and sales literature pertaining to the product you are considering or the intermediary is trying to sell. Get the intermediary to explain the full facts of the products, scope of cover and exclusions, as applicable.
• Insist on quality delivery and timely service. You can judge this by the turnaround time of the intermediary during the period of pre-sale when he or she is dealing with you.
• Fill up the proposal form yourself. Never ever sign on a blank proposal form. If you find terms in the proposal form that you do not understand, ask the intermediary to explain it to you.
• When you make premium payments through an Intermediary, check whether he is authorized to do so by the insurance company and insist on a  duly signed receipt immediately.
• After receipt of your policy, go through it thoroughly, and if you do not understand certain terms contact your intermediary and get them explained. Remember, for life insurance and for health insurance policies of a term of three years or more, there is a free-look period within which you may return the policy if you do not agree with the terms and conditions therein.
• Ask the intermediary questions about documents and procedures involved in making a claim and understand them completely. In the event of a claim, there may be other agencies you may have to intimate apart from the insurance company. Get complete details about what you are expected to do.

Healthcare costs are going up every day and illness and hospitalization affect our finances, our earning capacity, and our daily lives,

Here are some Dos and Don’ts for buying Health insurance

Dos

When you buy a health insurance policy you should:

• Know that there are restrictions on coverage
  
  
• Pay special attention to terms and conditions in the policy like:
  
  •         The clause excluding pre-existing diseases
  •         Waiting period before certain diseases can be covered
  •         Restrictions or limits on various expenses relating to hospitalization
  •         Co-payment, which means you have to share a part of the claim
  •         Pre-conditions for renewal
  •         Upper limits for age at entry and for renewal
    
    
• Disclose details of all pre-existing health problems including
  
  •         Major ailments
  •         Conditions like high blood pressure or diabetes
    
    
• The company may want medical test reports depending on age at entry, you should comply with all procedures and documentation requirements
  
  
• Check where and how the medical tests will be carried out
  
  
• Check who should bear the cost for the tests
  
  
• Pay the premium only after the insurer accepts your proposal
  
  
• Renew the policy meticulously for the rest of your life
  
  

Don’ts

• Conceal facts or you could face a dispute at the time of a claim
  
  
• Allow a gap of even one day in your policy renewal or your cover may be insufficient or useless

Overseas Health Policy: Dos and Don’ts

Dos

• Insure well ahead of your travel dates ensuring you have time for medical tests if required by the company
  
  
• Ensure you cover your entire period of stay abroad and all the countries you will be visiting
  
  
• Be aware of what your policy covers and does not cover. these policies cover not only hospitalization but could also cover travel-related risks like:
  
  •         Loss of passport
  •         Loss of cash
  •         Loss of baggage and
  •         Repatriation expenses
    
    
• Disclose details of all pre-existing health problems including
  
  •         Major ailments
  •         Conditions like high blood pressure or diabetes
    
    
• Comply with all procedures and documentation requirements the company may want including medical test reports depending on age at entry.
  
  
• Check where and how the medical tests will be carried out
  
  
• Check who should bear the cost for the tests
  
  
• Pay the premium only after the insurer accepts your proposal
  
  

Don’ts

• Conceal facts or you could face a dispute at the time of a claim

When you decide to buy an insurance policy:

• Check if the company selling the policy is registered with IRDAI
• Make sure you buy the policy through a genuine licensed agent or broker. Ask for an identity card or license
• You can also buy policies from the company directly
• Read the policy brochure/ prospectus carefully and get to know what the policy covers and does not cover