FAQ on Health Insurance

What are the criteria for deciding on the best health cover? Choosing a health cover for yourself must be done after careful analysis of your needs. In case you need a wide cover as also Income tax benefits the mediclaim policy with a family package cover could be a suitable option for you. You may also decide on the major ailments policy with annual, five and ten year cover options offering you a reasonable amount of premium savings. Those going for a wide coverage as also long term cover about five or ten years can opt for the term hospitalisation policy. This gives benefits that are not available under the normal mediclaim policy. Another convenience this policy offers is the non-requirement of every year renewal of the policy. If you plan to go for a less costlier health cover with tax benefit and limited coverage you could choose the Jan Arogya cover. For those closer to retirement age the long-term retirement benefit plan would be the ideal cover. Top How do you decide whether a disease was a pre-existing one or not? While filling up the proposal form for insurance you need to provide details of the illnesses you have suffered during your lifetime. Such disclosures are important else at a later stage if discovered you could end up losing out terribly. At the time of insurance, you should be aware whether you have any disease and whether you are undergoing any treatment. The insurers refer such health issues to their medical panel to differentiate between pre-existing and newly contracted illnesses. Top Personal Accident FAQs What insurance policies are available in India for accidental cover ? In India, Personal accident (individual/group), Janata personal accident and Gramin personal accident policies are available for accidental risks. Certain other policies like Motor vehicle policy, Videsh Yatra policy grant an add-on cover against personal accidents. Top Are there any other personal accident policies ? There are other accident policies for specified groups like students - Shishu Suraksha Policy, Bhagyashree for girl-children, Raj Rajeshwari for women and NRI Personal Accident policy for NRIs, etc. Top What is the difference between Personal Accident, Janta Personal Accident and Group Personal Accident policies ? Janta Personal Accident and Group Personal Accident policies are fixed sum insured policies whereas Personal Accident insurance is a variable Sum Insured policy which is based on income and other parameters like occupation of the person to be insured. Under Janta Personal Accident and Gramin Personal Accident insurance, the benefits available are fixed whereas under Personal Accident, the same can be selected from different tables of covers. Top Are Personal Accident (PA), Janta PA and Group PA long term policies ? All the policies mentioned above are annual policies but the Janta PA is available for longer periods up to 5 years. Top What is the scope of cover under Personal Accident policy ? The personal accident policy covers death, permanent total and partial disablement and temporary total disablement as selected by the client. The policy also offers cover in case of accidental death - the reimbursement of funeral expenses. It can also be extended to cover medical expenses arising out of accident up to 20 percent of the claim amount subject to maximum of 10 percent of the amount of insurance. Top What is permanent total/partial and temporary disablement? When an individual person is unable to do any duties for rest of his life, he is permanently disabled. When a person loses a part of limb or hearing etc. it is permanent partial disablement. Temporary total disablement arises when a person is confined to bed for a temporary period and is indisposed to attend to his duties for that period. Top What are the parameters for granting the cover under Personal Accident Policy ? Occupation, income, age and general health are the main parameters for granting Personal Accident cover. Insurance cover is granted up to 3 years to 5 years annual income of the person. Top Can non-earning people take Personal Accident insurance ? Non-earning members can also take Personal Accident insurance but for a smaller amount like Rs.50,000/- for the spouse and Rs.25,000/- for the children. Top Is there any income tax benefit for premium paid under Personal Accident insurance ? There is NO income tax benefit available against premium paid for Personal Accident insurance. Critical Illness FAQs Is the Critical Illness policy just another name for the Mediclaim policy ? Although the Critical Illness policy covers illness, it is not a Mediclaim policy. It is complementary to a Mediclaim policy, being an additional policy which can taken along with Mediclaim. Top What is the difference between Mediclaim & Critical illness policies? A Mediclaim policy is a reimbursement of the medical expenses whereas Critical Illness insurance is a benefit policy. Top What is a benefit policy ? Under a benefit policy on happening of an event, the insurance company pays the policyholder a lump sum amount. Whether the client spends the amount received on the medical treatment or not rests on his or her own discretion. Top Are all the illnesses are under the Critical Illness policy ? The Critical Illness policy covers only five major illnesses Cancer Kidney failure Organ transplant Multiple sclerosis and Coronary artery surgery (20 percent of Sum Insured) Top What is the amount of Insurance offered by a Critical Illness policy? Under a Critical Illness policy, the amount of insurance has to be selected by the client. It is at 4 levels %u2013 Rs.5 lakhs, Rs.10 lakhs, Rs.20 lakhs and Rs.25 lakhs. Top Under Critical Illness insurance while selecting the level of benefit, does the client exercise his choice or does the insurance company make a decision ? Under Critical Illness insurance if the client is financially well off then he can go for a higher level of insurance. If his annual earnings are less then he cannot opt for a higher level of benefits. Basically, the level of benefits depends upon the earning capacity of the person. Top Is there a minimum annual income requirement under Critical Illness insurance ? If the client is an income tax payer and his annual income is worth a minimum of Rs.2 lakhs, he can opt for Critical Illness insurance. Top When does the Critical Illness policy cover all the five illnesses ? As long as the policyholder was not suffering from any of the illnesses, the pre-existing illness exclusion applies to the Critical Illness policy also. Top What is the rate of premium calculated under the Critical Illness policy ? Under Critical Illness insurance, the premium depends upon the age and the sex of the person. For every age, there is a different premium charged. For instance, a 35-year old male will be charged a premium of Rs.1.53 per thousand whereas for a female of the same age, it is Rs.2.28 per thousand. For a 65-year male it is Rs.21.86. per thousand while a female of the same age will be charged Rs.15.25 per thousand. Top For how long can a Critical Illness policy be issued ? Under Critical Illness insurance, a policy can be issued only for one year and has to be renewed every year. And it is on the insurance company's discretion if they wish to renew the policy or not. Mediclaim FAQs In case an individual is already suffering from a disease, will Mediclaim still reimburse his or her expenses related to the disease? The insurance company will not reimburse any expenses related to any disease or injury which already existed at the time of first obtaining the insurance cover. Top Are all diseases and injuries covered by Mediclaim ? There are certain diseases and injuries that are not covered by this policy. These fall under basically 3 categories The injuries or diseases not covered in the first year of operation of the policy are: Cataract Benign prostatic hypertrophy Hysterectomy for menorrhagia or fibromyoma Hernia, hydrocele Congenital internal diseases Fistula in anus Piles Sinusitis and related disorders Note: The diseases listed above are only excluded from cover only for the first year of the policy and not afterwards. The injuries and diseases or medical conditions not covered at all under Mediclaim are: Cost of spectacles, contact lenses,hearing aids Dental treatment, surgery unless it requires hospitalisation Convalescence or rest cure Congenital external diseases Sterility Venereal diseases Condition directly or indirectly related to AIDS Pregnancy Circumcision, unless it is necessary under certain circumstances alone The injuries and diseases not covered under certain circumstances are: Intentional self-injury Use of intoxicating alcohol and / or drugs Diseases or injuries arising in the first 30 days from the commencement of policy (this does not include the diseases excluded in the first year of operation of the insurance policy), however if a medical practitioner named by the insurance company states that the policyholder had no knowledge of the existence of the disease, then it will be covered (this also does not apply if the insured had been covered under this policy or group insurance scheme with any Indian Insurance Company, in the immediately preceding 12 months) Top Are the tests prescribed by the doctor be reimbursed under Mediclaim ? All charges incurred at the hospital or nursing home primarily for diagnostic purposes such as X-rays, blood analysis, ECG, etc will be reimbursed only if they are consistent with or incidental to the diagnosis and treatment of the ailment for which the policyholder has been hospitalised and not otherwise. Top Can the Mediclaim the insurance contract be cancelled midway? The policy can be cancelled at any time during the course of its operation. In such cases, the insurance company will refund the premium paid (on the basis of the table provided below) only if no claim has been up to the date of cancellation. Date of cancellation Amount to be refunded within 1 month quater of the annual rate Within 3 months half of the annual rate After 6 months No refund Note: The policy may also be cancelled at any time by the insurance company by giving the insured person 30 days notice through a registered letter sent to the last known address of such person. such circumstances, the insurance company has to refund the premium pro-rata for the un-expired period of insurance. The insurance company is however liable for any claim made prior to the date of cancellation. Top What is the coverage offered by the Mediclaim policy ? A Mediclaim policy reimburses hospitalisation expenses for the treatment of sickness or accident occurring during the period of insurance. Top What type of hospitalisation expenses are covered by Mediclaim ? Mediclaim covers room, boarding charges, nursing expenses, surgeon, anaesthetist / doctor's fees, blood, oxygen, operation theatre charges, x-ray, other tests pertaining to sickness, etc. Top What kinds of medical tests are covered by Mediclaim ? Mediclaim covers medical tests connected with the sickness. Hospitalisation expenses for medical check up only are not covered. There has to be positive existence of diseases to claim under Mediclaim. Top Can treatment can be taken at any hospital or at a particular hospital under Mediclaim ? Under Mediclaim, treatment at all the hospitals / nursing homes registered with local authorities is allowed. In case there is no registration with the local authority the hospital should have at least 15 in-patient beds, a fully operational operation theatre, qualified nursing staff and doctor in charge. Only if these conditions are satisfied can the person go to his or her hospital of choice. Top Is there a minimum time limit for stay within the hospital under Mediclaim ? Under Mediclaim, the minimum stay within the hospital must be for a minimum of 24 hours. However for dialysis, chemotherapy, eye surgery, etc - the stay can be for less than 24 hours. Top What is considered as "domiciliary hospitalisation" under Mediclaim ? When the condition of the patient is such that he cannot be moved to the hospital or when there is no bed available in any of the hospitals, then the treatment taken at home only if it is like the treatment given at the hospital / nursing home is reimbursable under the Mediclaim policy. Top Are there any other restrictions on domiciliary hospitalisation benefits under Mediclaim ? Under Mediclaim, the limit of compensation is low and for certain diseases like asthma, bronchitis, diabetes, epilepsy, etc it is not available. Top Does Mediclaim cover any expenses besides hospitalisation costs ? Mediclaim covers pre-hospitalisation (limited up to 30 days) and post-hospitalisation (limited to 60 days from discharge) expenses also if they are connected with the sickness / accident for which the hospitalisation takes place. Top Under Mediclaim, is the limit of insurance per sickness or annual ? Under Mediclaim, the amount of insurance is the limit until which the insurance company will pay during any policy period. They are annual limits for all sicknesses / accident during a year. Top What happens when the limit of insurance is exhausted under Mediclaim ? Under Mediclaim, future expenses are not covered during the same policy period however when the policy is renewed, the limit of insurance starts afresh. Top Under Mediclaim, does a sickness for which a claim is lodged get covered under a future insurance policy or does it become pre-existent for the next policy term ? Under Mediclaim, a sickness for which a claim is lodged does not become pre-existent. It is covered provided the policy is renewed within time limits and there is no break in the term of the insurance policy. In case there is a break in the term of insurance (up to 7 days allowed subject to certain conditions) then it will definitely become pre-existent and exclusions will apply. Top Is the maternity benefit extension available under an individual Mediclaim policy ? No maternity benefit extension is available under an individual Mediclaim policy. Top What is family discount under Mediclaim ? Under Mediclaim, when the husband or the wife and children or dependant parents are covered under same policy, a discount of 10 percent is given on the total premium by way of family discount. Top What are the factors which determine the premium payable under Mediclaim ? Under Mediclaim, the age and the amount of cover are the factors that decide the premium. Top What are the minimum and maximum amounts for which a Mediclaim policy can be taken ? Under Mediclaim, the minimum amount that can be insured for is Rs.15,000/- and the maximum amount is Rs.5,00,000/- In any case, the amount for which the insurance company may grant insurance is at their own discretion. Top Does Mediclaim offer any advantages on renewal ? On renewal of Mediclaim for every claim free year. a bonus of five percent per year (maximum 50 percent) is allowed and after four continuous renewals, the cost of medical check up to the extent of one percent of cumulative insurance for the last four years is allowed. Top Who will receive the claim amount under Mediclaim if the policyholder dies during the time of treatment ? Under Mediclaim, the claim amount is paid to the nominee of the policyholder. In case there is no nominee made under the policy, then the insurance company will insist upon a succession certificate from a court of law for disbursing the claim amount. Alternatively, the insurers can deposit the claim amount in the court for disbursement to the next legal heirs of the deceased. Who should the policyholder contact in the event of claim under Overseas Mediclaim Policy ? In the event of claim under Overseas Mediclaim Policy the policyholder can contact Mercury International Assistance and Claims Limited P.O.Box 673, Brighton, Sussex, BNI 4, EZ, England. Top What compensation is provided under the Individual Personal Accident Policy? Under the Individual Personal Accident Policy: If the accident results in death, the full Capital Sum Insured must be paid to the Insured%u2019s beneficiaries. In the accident results in permanent disablement that involves the total loss of both eyes or two limbs or one eye and one limb, the full Capital Sum Insured is payable. In case the accident results in loss of one eye and one limb, then only 50 percent of the Capital Sum Insured will be paid. In case the accident results in partial disablement of certain parts of the insured%u2019s body, only a specified percentage of the Capital Sum Insured will be paid. In case there is disablement excluding injuries that are not visible or verifiable through medical tests like sprains, muscular spasms, etc ALL the benefits listed above have to be paid PLUS 1 percent of the Capital Sum Insured subject to a maximum of Rs.3000 per week over the Capital Sum Insured. However the total period of compensation will not exceed 104 weeks or 2 years approximately. Top Which discounts are available under the Group scheme for the Personal Accident Policy? There are chiefly two types of Group Schemes, first called Group A where an employer-employee relationship exists as in corporate firms, companies, etc. The second known as Group B is where an employer-employee relationship does NOT exist as in a club, association, club or any social institution. Group discounts are applicable for groups of people not exceeding 500. The larger the group, the higher are the discounts given by the insurance company. 101-300 people 15 percent of the total premium 301-500 people 25 percent of the total premium 501-1000 people 30 percent of the total premium 1001-5000 people 35 percent of the total premium 5001-50000 people 40 percent of the total premium > 50000 people 50 percent of the total premium The benefits mentioned within the Group scheme are all those mentioned in the Personal Accident Policy except the Cumulative Bonus and the Education Fund. Top What are the different benefits that can be claimed under the Mediclaim insurance policy in event of hospitalisation? Different heads of benefits under hospitalisation: Room boarding expenses by the hospital nursing home Nursing expenses Surgeon, anaesthetist, medical practitioner, consultants, specialist%u2019s fees Anaesthesia, blood, oxygen, operation charge, surgical appliances, medicines and drugs, diagnostic material and x-rays, dialysis and chemotherapy, radiotherapy, pacemaker, artificial limbs and cost of organs and similar expenses All the above benefits are limited to the max sum insured The minimum period of hospitalisation should be for 24 hours. However for certain treatments this limit is not applicable when a package charges are levied for treatment by the hospital. Top Who is entitled to an overseas mediclaim policy? Anyone traveling abroad for business or pleasure or as student going for higher studies can qualify for an Overseas Mediclaim. Needless to say, this policy does not cover trips abroad for pre-planned medical treatment. Top What is the extent of liability under an overseas mediclaim policy? For trips where the destination does NOT include the United States of America and its Northern neighbour, Canada, the extent of liability is limited to $50000. For trips where the destination does include the USA and Canada, the extent of liability can be as high as $100000. Top What is the procedure to be followed to apply for cover under an Overseas Mediclaim policy? To acquire cover under an Overseas Mediclaim policy, the traveler must submit his Visa details and its validity Country of visit Passport details Name and address of the sponsor, a certificate giving details of employment / studies and its duration Period of cover required Medical examination certificate as per the prescribed guideline Income certificate of the sponsor in case of student Top What benefits can be made available to the insured under a Gramin Accident Insurance policy? Any individual aged between 10 to 70 years of age irrespective of his or her occupation can qualify for protection under the Gramin Accident insurance scheme. The benefits are subject to the level of the loss suffered by the insured individual. Death by accident Rs.10000/- Totally irrecoverable loss of use of both eyes or two limbs or one eye and one limb due to accident Rs.10000/- Total irrecoverable loss of use of one eye or one limb due to accident Rs.5000/- Permanent total disablement due to accident Rs.10000/- Top What is the Premium Payable under the Gramin Accident insurance scheme? The Premium Payable under the Gramin Accident scheme increases directly with the number of years that the cover is sought for. No of Years Single Gross Premium (In Rupees) 1 5/- 2 10/- 3 12.50 4 15.60 5 19/- Top What are the benefits available to the insured under the Janata Personal Accident Policy? Under the Janata Personal Accident Policy, any individual between the age of 10 to 70 years of age irrespective of his occupation can qualify for protection against any untoward mishap Benefits Amount of indemnity Death due to accident Rs.25000 Loss of use of 2 limbs/sight in both eyes Rs.25000 Total and irrecoverable loss of use of one limb/sight in one eye due to accident Rs.12500 Permanent total disablement due to accident Rs.25000 Top What is the Premium Payable under the Janata Personal Accident scheme? Under the Janata PAP scheme, the Premium Payable increases with the number of years that the cover is sought for. No of Years Single Gross Premium (In Rupees) 1 15/- 2 28/- 3 40/- 4 51/- 5 57/- What is the meaning of "Personal Accident" in legal insurance terminology? Personal Accident is defined as an accident owing to external, violent and visible means in legal insurance terminology. Top What does 'External' mean with regards to personal accident insurance policies? With reference to personal accident insurance policies, 'External' is any impact that is outward and on the exterior. Internal impact like diseases and natural causes of sickness is not covered under this policy. Top What does 'violent' mean with reference to personal accident policies? The force of the impact that caused injury in relation to the compensation claimed can be termed as 'violent' when referring to personal accident policies Top What does 'visible' signify with reference to personal accident policies? With respect to personal accident policies, 'visible' is denoted by the result of the impact, which caused the injury. The injury must be either physically or clinically visible. Top What is Permanent Total Disablement? Permanent Total Disablement refers to the absolute disability of an injured person after which he or she cannot engage in any employment or occupation of any description on a permanent basis. Top What does 'Loss of limbs' mean with reference to Permanent Total Disablement? An actual loss by physical separation of the hand's and/or leg's, clearly discernible as loss of hand up to the wrist and/or foot up to the ankle can be classified as a 'Loss of limbs' while referring to Permanent Total Disablement. Top What does 'Loss of eyes' mean with reference to Permanent Total Disablement? An actual loss of sight of eye and or eyes can be classified as a 'Loss of eye/s' while referring to Permanent Total Disablement. Top What is Temporary Total Disablement? Any accidental injury that is the sole and or direct cause of total, yet temporary disablement as long as the injured person is totally and completely unable to engage in any employment or occupation of any description can be termed as Temporary Total Disablement. Top What is "Cumulative Bonus"? The compensation payable for the death, loss of limb's or sight or permanent total disablement is normally increased by 5 percent of the Capital Sum Insured for every completed year of insurance. This compensation payable in event of any of the abovementioned medical contingencies is known as Cumulative Bonus. However, the cumulative bonus is subject to a amount that can never exceed 50 percent of the Capital Sum Insured. Top What is Mediclaim insurance? Mediclaim insurance consists of the reimbursement of hospitalisation and/or domiciliary hospitalisation expenses for any illness/diseases or injury sustained by the insured individual. Top What does 'Hospital' mean with regards to mediclaim insurance policies? Any institution established for the indoor care and treatment of sickness and/or injuries, which is duly registered and supervised actively by a registered medical practitioner OR Any establishment With at least 15 patient beds With a fully equipped operation theatre of its own if surgical procedures are carried out Employing fully qualified nursing staff around the clock Having fully qualified doctors in charge around the clock can be classified as a 'Hospital'. Note: For Class 'C' towns, the number of beds is relaxed to 10 (ten) Ayurvedic or institutions practising alternative medicine therapy also qualify as 'Hospitals' Top What is meant by 'Hospitalisation'? Any instance when and where the insured individual is hospitalised for a minimum period of 24 hours can be termed as 'Hospitalisation'. However, for specific treatment like dialysis, chemotherapy, radiotherapy, laser eye surgery, dental surgery, etc when the patient is discharged on the same day is also considered as 'Hospitalisation'. Top What is 'Domiciliary Hospitalisation'? "Domiciliary Hospitalisation' is any instance when and where the insured individual requires medical treatment for more than three days for an illness / disease / injury that in the normal course would require hospitalisation and is conducted at his or her home within India due to The condition of the patient being such that he cannot be moved to the hospital Lack of hospital accommodation Top What is 'Any one illness' with reference to mediclaim 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 with respect to any mediclaim policy. Top What is meant by Pre-hospitalisation and Post-hospitalisation expenses? The relevant medical expenses incurred during 30 days prior to hospitalisation are known as 'Pre-hospitalisation expenses'. Medical expenses incurred for 60 days after hospitalisation are known as 'Post-hospitalisation expenses'. Top What are the health check-up benefits available under the mediclaim policy? The Mediclaim policy provides reimbursement of medical expenses for health check-up at the end of every 4 claim-free years at the rate of 0.1 percent of the Capital Sum Insured.

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