FACTS ABOUT HEALTH INSURANCE

2. Health insurance is a term that relates to a
contract where in thr individual contributes a
regular premium with the expectation that if
something happens, the insurer will provide the
individual in question.
FOR EXAMPLE:- In case of an accident, the
insurer will cater to the expenses, provide d that
the individual has taken the insurance.

3. A health insurance policy would normally cover
expenses reasonably and necessarily incurred
under the following heads in respect of each
insured person subject to overall ceiling of sum
insured (for all claims during one policy period)
1. Room and boarding expenses
2. nursing expenses
3. fees of surgeon, anaesthetist etc

4. 1. The policy should provide for reimbursement of
hospitalisation/domiciliary hospitalisation expenses for
illness/disease.
2. Expenses on hospitalisation for minimum period of 24 hours are
admissible. However,the limit is not allowed to specific treatment
i.e dialysis ,chemotherapy, radio therapy etc
3. Relevant medical expenses incurred prior to up to certain period ,
say 30 days and after hoapitalisation up to a certain period .
4. Health policies may also contain a provision from
reimbursementof cost of health check up

5. Insurance companies have tie-ups arrangements with a
network of hospitals in the country, If the policy holder
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
will arrange the direct paymentt to the hospital. Excess
beyond sub limits prescribed by policy are not covered and
have to be settled by the first party itself. Insurance
companies also offer various other benefits as add ons or
riders, for example: hospital cash, critical illness benefits
etc

6. 1.Filling the proposal form: majorly contains all your personal information for eg:
name, address, sum insured etc
2. Declaration of good health/medical certificate: a person should be give a
declaration of his good health; in case of heath problems, he should submit the
certificate
3. Medical report: if the age of a person is above 45yrs, then a medical examination
is required
$. Payment: to avail tax benefit, the premium should be paid through cheque
5. Issue of policy documents: after the formalities and submission of documents
are submitted, the policy document are issued
6. Issue of photo card by TPA : TPA are authorities by IRDA to settle the
insurance claims on behalf of insurance companies. They issue photo identity
cards and help in insuring cashless treatments. They provide a list of hospitals and
provide the amount directly to the hospitals on behalf of the insurer

7. Difference between cashless and
reimbursement claim
Cashless claim Reimbursement
Cashless claims means that the
policy holder will not pay any
amount to the hospitals and
that the hospital will get the
payment directly from the TPA
up to the limit of sum insured.
 The customer first pays to the
hospital on his own and then
asks for the reimbursement
oh his claim from insurer or
TPA. TPA or insurer will pay
the money the due amount.

8. INTIMATION OF CLAIM: in case of the planned hospitalisation, the
policy holder can inform the claim team that he/she is planning to
avail hospitalisation or he can intimate after he/she gets gets
hospitalised.
REGISTRATION OF CLAIM: it’s a method of assigning a reference no.
to the claim. Its just like giving an identity to the claim using which
the claim can be traced at any moment. Once the claim intimation is
received and the policy number as well as insured person’s particular
are matched, the registration and reference no. are done.

9. VERIFICATION OF DOCUMENTS: the next step is to get
all the documents verified. Following documents and
information needs to be processed
1. Documnetary eveidence of illness
2. Treatment provided
3. In-patient duration
4. Investigation reports
5. Payment made to the hospital
6. Further advice for the treatment
7. Payment proofs for implants

10. TAKING STOCKS OF THE BILLING INFORMATION: billing provides
indemifying expenses incurred in the treatment. Bill is bifurcatedinto
various heads in the claim processing cycle
1. room, board and nursing expenses
2. Charges for ICU
3. Surgeon, anaestetist, medical practitioner, consultancy fees etc
4. Ambulance charges
5. Medicines and drugs etc
6. Investigation, operation thetre charges etc

11. CODING OF CLAIMS: codes have been assigned to diseases by the
WHO which are known as international classification of dieases
codes. In india, insurers have started relying on coding and insurance
information bureau (IIB)which is a part of IRDAI and has started an
information bank where such information can be analysed .
PROCESSING OF CLAIM: a health insurance policy contains various
provisions which explains whether a claim is payable under a policy or
not and if the claim is payable, then what would be the net payable
amount.

12. ADMISSIBILITY OF A CLAIM: once the health claim is been
processed, it has to be checked whether a health claim is admissible or
not.
1. The details of the person in policy must match the details
mentioned in the insurance policy, so as to make sure there are no
frauds.
2. The time of admission of the patient falls in the period of
insurance.
3. The policies have different definition of ‘ hospital or nursing
homes’ thus it needs to be checked that hospital where the perosn
was submitted must be a part of the definition under policy.

13. EMPLOYEES STATE INSURANCE:Employees’ State Insurance Scheme :
Initially the scheme covered blue collared employees and their dependents
against loss of wages because of sickness, maternity, temporary disability of
permanent disability and death due to employment injury. It also covers
funeral expenses. Now, it covers all employees earning wages up to Rs.15000.
ESI Scheme is contributory in nature. Here, both employee and employer
have to contribute 1.75% of the wages and 4.75% of the wages paid /
payable in respect of the employees in every wage period respectively.
Employees State Insurance Corporation is the concerned agency which
practically implements ESI scheme through its own hospitals and
dispensaries. ESI covers medical care which comprise of outpatient care,
hospitalization, medicines and specialist care.

14. Central Government Health Scheme :
The scheme covers employees and retired employees of the central
government and employees of autonomous and semi-autonomous
and semi-government organisations. CGHS was launched in 1954 to
provide comprehensive health care. The contribution is made both
by employee as well as the Central Government, i.e. employer.
Employer does a major contribution to the funds as compared to the
employee. The scheme covers medical care, emergency services in
allopathic system, home visits, free medicines, specialist
consultations, domiciliary visits and diagnostic services. These
services are given by the hospitals empanelled under CGHS. Free
drugs are provided in the dispensaries owned by CGHS.

15. Universal Health Insurance Scheme (UHIS) :
Another scheme launched by the government in health insurance is
Universal Health Insurance Scheme targeting the poor section of
society. This scheme provides the protection to poor below poverty
line against financial risk by giving health care with the sum assured
of Rs.30,000. For availing the health care cover of Rs.30,000, a
premium of Rs.165 for a person, Rs.248 for a family of five and
Rs.330 for a family of seven, is to be paid on yearly basis.
Self Help Group Insurance :
This insurance scheme was launched in 2004 for Self Help Group
(SHG). Under this policy, self help groups can avail sum assured of
Rs.10,000 by paying the premium of Rs.120.

16. Community based Health Insurance or Insurance offered by NGOs :
This scheme is offered by NGOs which target poor population living in
communities. Members pay a certain yearly amount on advance basis for
specified services. In this scheme, the premium is not based on income,
rather a fixed rate of premium is paid by the insured. Fixed rate of
premium is considered better because if the premium is income based,
then premium will become progressive in nature. Major portion of
funding of these schemes comes from government grants and donations
and some portion relates to the contribution from patients. Some of the
popular community based health insurance scheme are : SEWA,
Tribhuvandas Foundation (TF), Action for community organization,
rehabilitation and development (ACCORD), Voluntary Health Services
(VHS) etc.

17. Employer based scheme :
Facilities like reimbursement of employee’s health expenditure for
out patient care and hospitalization, fixed medical allowance,
group insurance are often offered by the employer in both public
and private sector offers. Various departments of government
such as The Railways, Plantation sector and Mining sector. Even
Defence and Security forces run their own health services for
employees and their families.

18. Floater Health Insurance Policy :
A single sum assured is available to all members of the family, the
sum assured can be used by any family member for any number of
time i.e. a family consists of self, spouse and two children have a
health insurance policy with the sum assured of Rs.2 Lacs. Any family
member can avail the benefit of Rs.2 Lacs for N numbers of times. In
this policy the premium paid is the premium paid for the member of
highest age in the family.
Common Exclusions :
Cost of spectacles, contact lenses, hearing aids etc.
Dental treatments, Except in the case of accident
Cosmetics or aesthetic precedures :
Naturopathy treatment related to child birth, pregnancy etc.

19. Group Health Insurance Policy :
This policy is available to any group, be it employer-employee group, non employer-
employee group, associations or institutions groups i.e. Holders of the same credit
cards, savings bank account holders etc.
This policy is issued in the name of the group which is called INSURED under group
insurance the list group description will contain the names of the members and its
eligible family members. The coverage under the policy is the same as under individual
mediclaim policy with the following differences :
Cumulative Bonus and Health Check-ups are not payable
Group discount in the premium is available
Renewal premium is subject to claims made during the previous policy
Maternity benefit extension is available at extra premium. Options for maternity
benefits has to be exercised at the inception of the policy period and no refund is
allowable in the case of insured cancellation of this option during the currency of the
policy.

20. Critical Illness Insurance Policy :
An insurance cover provided to the insured with the lump
sum amount in case the insured is diagnosed with the
critical illness.
If an insured is diagnosed as suffering from a disease a
lump sum cash payment is made to the insured. It
depends upon the terms of the policy. The payment can
be on the regular basis or the payment could be made
when the policy holder is under going the surgery.

21. Overseas medical Policy :
This policy is applicable for indian residents who have
gone overseas either on official or on personal purposes.
This policy helps to reimburse the expenses done in
respect to illness or accidents sustained overseas by the
residents. This insurance scheme was introduced in 1984,
modified many times to provide additional benefits such
as in-flight personal accidents, loss of passport features in
the cover.