Understanding your Health Insurance policy

Posted by shivanikapoor on June 29th, 2017

According to world Health Organization, a mere 3.9 percent of the GDP was spent on insurance in India in the year 2013.The out-of pocket expenses on healthcare stood at 86 percent in India as compared to 20.9 percent in the US and 53.9 percent in UK.

It is important to have sufficient health insurance cover in order to meet medical emergencies. It is equally important to understand the provisions of any health insurance product that you may be holding, to avoid unpleasant surprises at the time of making a claim.

Points to Remember

Pre-Existing Illnesses

Pre-existing illnesses are illnesses that existed before you bought your policy. Most insurers do not cover illnesses that existed within 4 years prior to the first policy. Only after 4 years of continuous insurance coverage, the insurance company may consider covering pre-existing illnesses as well.

Waiting Period

All health insurance policies come with a waiting period. For the health plans offered by general insurers, the waiting period is usually 30 days. The critical illness cover from a life insurer usually specify a waiting period of 90 days. During the waiting period, you will not be covered.

Survival Period

In case of critical illness coverage, the insured has to survive for a minimum of 30 days (or as per the policy terms) after the date of diagnosis in order to claim the benefits.

Minimum Stay

In order to claim hospitalization benefits, the insured should have been hospitalized for a minimum period of 24 hours (or as per the policy terms). This condition does not apply to hospitalization due to accident.

Cashless Facility

In case your policy offers cashless hospitalization, you need not pay any cash when admitted to a network hospital with which the insurer has a tie-up. The bills will be settled by a Third Party administrator (TPA) on behalf of the insurance company. In case you are admitted in a non-network hospital, you need to settle the bills directly and get it reimbursed by the insurance company.

In case of cashless hospitalization, you need to give intimation of hospitalization to the TPA within 24 hours of hospitalization.


It is important to read your policy document and understand what is not covered under the policy. Besides pre-existing illnesses, certain specified illnesses may be excluded in the first year. There are certain standard exclusions across all health insurance policies. Cost of dental treatment, venereal disease, AIDS, congenital diseases, intentional self-injury, etc. usually fall under standard exclusions.

Specified Illnesses and Surgeries

Critical illness policy covers illnesses that are specified in the policy document. Surgical cash benefit covers specified surgeries. It is important to read the policy document and familiarize yourself with the illnesses and surgeries that are covered.

Grace Period

Grace period allows premiums to be received for a certain period of time after the premium payment due date. A grace period of 15 days is allowed, in health insurance products offered by general insurance companies.

Health products from life insurance companies allow a grace period of 30 days from the due date, to pay your premium. Usually the coverage will continue during the grace period.

Grievance Redressal

Any grievance related to your Medical Insurance Policy should first be taken up with the insurer. The complaint should be acknowledged by the insurer within 3 working days. In case you are unhappy with the resolution of your grievance, you can register a complaint with the Integrated Grievance Management System of IRDAI by logging on to their portal.

You can lodge a complaint directly with IRDAI over phone (Toll free number 155255) or by sending an e-mail to complaints@irda.gov.in. The IRDAI initiates resolution of complaints registered with it by taking it up with the insurance company. The insurer is expected to resolve grievances within 15 days.

Understand your health policy well in order to avoiding delays and hassles at the time of making a claim.

Source: tomorrowmakers.com/articles/health-insurance/understanding-your-health-insurance-policy

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Joined: June 8th, 2017
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