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Medical Insurance-Family : FAQ- My Insurance Bazaar

Medical Insurance-Family : FAQ- My Insurance Bazaar

What is a Medical Insurance (Family Floater) Policy
Why is Medical Insurance needed
What is insured
What is not insured
Which are the diseases which are covered after first year/ second year
Add-on Insurance Covers
Are maternity-related expenses insured
What are Pre-Existing Diseases
What is Pre and Post hospitalization treatment
What is Domiciliary Hospitalization
Who can be insured
Floater Sum Insured
How is premium calculated
What is Cumulative Bonus
Is there an Income Tax exemption on the premium
Typical Claims Procedure
Duration of Hospitalization
Day Care Treatment
Cashless Facility
Third Party Administrator (TPA)
Panel Hospitals
Health Cards
Portability


What is a Medical Insurance (Family Floater) Policy
This policy covers expenses incurred by an insured member of a family in a hospital in India towards treatment of an illness, disease or accident.

Why is Medical Insurance needed
Lifestyle diseases are on the rise. Some of us are additionally exposed to occupational health hazards. Despite all precautions, we do run the risk of contracting an illness or meeting an accident. Healthcare is expensive. Technological advancement in treatment of most diseases has rendered cost of treatment beyond the means of most of us. In an unfortunate situation, where we face an expensive treatment, we either have to draw from our savings or borrow money. Medical insurance provides much needed financial relief.

What is insured
Room, Boarding charges, nursing charges, fee payable to surgeon/ anesthetist / specialists/ consultants, the cost of anesthesia / diagnostic tests / medicines/ blood/ oxygen/ appliances like pacemaker/ artificial limbs/ organs/ operation theatre charges/ dialysis /chemotherapy / radiotherapy and similar such expenses are covered.

What is not insured
Ordinarily the following conditions or expenses are not insured by most insurance companies in India. But some of these exclusions can be covered after a specified period or on payment of additional premium.

  • Pre-existing diseases i.e. Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company. Pre existing diseases will be covered after a maximum of four years since the inception of the policy.
  • Any disease contracted during the first 30 days of inception of policy except in case of injury arising out of accident.
  • Certain diseases such as cataract, piles, hernia, and sinusitis etc. are excluded for specified periods if contracted or manifested during the currency of the policy.
  • Injury or Diseases directly or indirectly attributable to War, Invasion, Act of Foreign Enemy, and War like operations.
  • Cosmetic, aesthetic treatment unless arising out of accident.
  • Cost of spectacles, contact lenses and hearing aids.
  • Dental treatment or surgery of any kind unless requiring hospitalization.
  • Charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations, without any treatment.
  • Naturopathy or other forms of local medication.
  • Pregnancy & childbirth related treatment.
  • Intentional self-injury / injury under influence of alcohol, drugs.
  • Diseases such as HIV or AIDS.
  • Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the attending physician.
  • Convalescence, general debility, run-down con

 

Which are the diseases which are covered after first year/ second year
The expenses on treatment of certain diseases such as cataract, hernia, piles, sinusitis, benign Prosthetic Hypertrophy, Hysterectomy for Menorrhegia or Fibromioma etc. which are excluded for specified periods can be insured subsequently.

Add-on Insurance Covers
Insurance companies in India, offer certain add-on covers either free of any charge or at additional premium.  Some examples are as follows.  

  • Ambulance Charges for shifting the insured from residence to hospital.
  • Ayurvedic/Homeopathic and Unani system of medicine up to a limit
  • Pre-hospitalization expenses
  • Post-hospitalization expenses
  • Domiciliary hospitalization

 

Are maternity-related expenses insured
Most insurance companies do not cover maternity and related conditions but some companies have specific plans which cover maternity after specified waiting periods generally 2-4 years.

What are Pre-Existing Diseases
Any condition, ailment or injury or related condition(s) for which insured person had signs or symptoms and/or was diagnosed and/or received medical advice/treatment within 48 months prior to his/her health policy with the company. Pre existing diseases are generally covered after a maximum of four years since the inception of the policy.

What is Pre and Post hospitalization treatment
Medical Expenses incurred immediately before or after the Insured Person is hospitalised, provided that (1) such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalisation was required, and (2) the In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company. Most insurance cover pre and post hospitalization treatment for 30 and 60 days respectively.

What is Domiciliary Hospitalization
Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any o f the following circumstances.

  • the condition o f the patient is such that he/she is not in a condition to be removed to a hospital, or
  • the patient takes treatment at home on account o f non availability o f room in a hospital.

 

Who can be insured?
Most insurance companies cover the proposer, spouse and two dependent children in a family. The maximum age up to which one can take insurance is ordinarily 60 years but some insurance companies also insure those who exceed this age limit.

Floater Sum Insured
Sum insured is an amount chosen by a customer as the limit up to which he can claim hospitalization expenses in a year for self or for other insured family members. Floater Sum insured means the Sum Insured as specified for the proposer under a policy and is available for any or all the members of his /her family for one or more claims during the tenure of the policy.

How is premium calculated
Premium charged by an insurance company depends on the sum insured, family size, age, past claims experience etc. Some insurance companies have divided the country into various zones and charge the premium based on the geographical zone in which the insured undertakes to seek hospitalization.

What is Cumulative Bonus
Cumulative Bonus is an increase in the Sum insured by a specified percentage, offered by insurance companies without charging any premium, for every claim free year, subject to a certain maximum. An important point to be remembered is that the policy should be renewed without a break to avail of the cumulative bonus.

Is there an Income Tax exemption on the premium
Premium paid for medical insurance policy is eligible for tax deduction under section 80 D of the Income Tax Act. As per current IT rules you can get an exemption as follows.

  • up to a maximum sum of Rs.15,000/- from your taxable income under Section 80-D for Health Insurance Premium paid for self, spouse, dependent children
  • Additional exemption of up to Rs. 15,000/- if you pay the medical insurance premium of parents. This exemption limit goes up to Rs 20,000/- if the parents are above 65 years in age

 

Typical Claims Procedure
An insured patient has to show his / her health card at hospitals for identification and verification of insurance particulars. Post-verification, the line of treatment and the charges there for are fixed by a hospital and the same are conveyed to the insurance company (or TPA). The TPA authorizes the treatment, based on the policy conditions, limits and sub-limits, and treatment is dispensed by hospitals. On conclusion of treatment the patient is discharged and the hospital bills are settled by the TPA directly.

Duration of Hospitalization
An insured patient has to be hospitalized for a minimum period of 24 hours consecutively in in-patient care for a claim under a Medical insurance policy to be admissible. This restriction, however, does not apply to Day Care Treatment, where such admission could be for a period o f less than 24consecutive hours.

Day Care Treatment

Though the Medical Insurance policies require hospitalization of more than 24 hours for a claim to be admissible, there are treatments which require hospitalization for shorter periods and are also are paid for by insurance companies.

Day care treatment refers to medical treatment, and/or surgical procedure which is undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and which would have otherwise required a hospitalization of more than 24 hours. Treatment otherwise taken on an out-patient basis is not included in the scope of this definition.

Day Care Procedures that are covered under a Medical Insurance Policy are -

Microsurgical operations on the middle ear

1. Stapedotomy

2. Stapedectomy

3. Revision of a stapedectomy

4. Other operations on the auditory ossicles

5. Myringoplasty (Type -I Tympanoplasty)

6. Tympanoplasty (closure of an eardrum perforation/reconstruction

of the auditory ossicles)

7. Revision of a tympanoplasty

8. Other microsurgical operations on the middle ear

Other operations on the middle & internal ear

9. Myringotomy

10. Removal of a tympanic drain

11. Incision of the mastoid process and middle ear

12. Mastoidectomy

13. Reconstruction of the middle ear

14. Other excisions of the middle and inner ear

15. Fenestration of the inner ear

16. Revision of a fenestration of the inner ear

17. Incision (opening) and destruction (elimination) of the inner ear

18. Other operations on the middle and inner ear

Operations on the nose & the nasal sinuses

19. Excision and destruction of diseased tissue of the nose

20. Operations on the turbinates (nasal concha)

21. Other operations on the nose

22. Nasal sinus aspiration

Operations on the eyes

23. Incision of tear glands

24. Other operations on the tear ducts

25. Incision of diseased eyelids

26. Excision and destruction of diseased tissue of the eyelid

27. Operations on the canthus and epicanthus

28. Corrective surgery for entropion and ectropion

29. Corrective surgery for blepharoptosis

30. Removal of a foreign body from the conjunctiva

31. Removal of a foreign body from the cornea

32. Incision of the cornea

33. Operations for pterygium

34. Other operations on the cornea

35. Removal of a foreign body from the lens of the eye

36. Removal of a foreign body from the posterior chamber of the eye

37. Removal of a foreign body from the orbit and eyeball

38. Operation of cataract

Operations on the skin & subcutaneous tissues

39. Incision of a pilonidal sinus

40. Other incisions of the skin and subcutaneous tissues

41. Surgical wound toilet (wound debridement) and removal of diseased tissue of the skin and subcutaneous tissues

42. Local excision of diseased tissue of the skin and subcutaneous tissues

43. Other excisions of the skin and subcutaneous tissues

44. Simple restoration of surface continuity of the skin and subcutaneous tissues

45. Free skin transplantation, donor site

46. Free skin transplantation, recipient site

47. Revision of skin plasty

48. Other restoration and reconstruction of the skin and subcutaneous tissues

49. Chemosurgery to the skin

50. Destruction of diseased tissue in the skin and subcutaneous tissues Operations on the tongue

51. Incision, excision and destruction of diseased tissue of the tongue

52. Partial glossectomy

53. Glossectomy

54. Reconstruction of the tongue

55. Other operations on the tongue

Operations on the salivary glands & salivary ducts

56. Incision and lancing of a salivary gland and a salivary duct

57. Excision of diseased tissue of a salivary gland and a salivary duct

58. Resection of a salivary gland

59. Reconstruction of a salivary gland and a salivary duct

60. Other operations on the salivary glands and salivary ducts

Other operations on the mouth & face

61. External incision and drainage in the region of the mouth jaw and face

62. Incision of the hard and soft palate

63. Excision and destruction of diseased hard and soft palate

64. Incision, excision and destruction in the mouth

65. Plastic surgery to the floor of the mouth

66. Palatoplasty

67. Other operations in the mouth

Operations on the tonsils & adenoids

68. Transoral incision and drainage of a pharyngeal abscess

69. Tonsillectomy without adenoidectomy

70. Tonsillectomy with adenoidectomy

71. Excision and destruction of a lingual tonsil

72. Other operations on the tonsils and adenoids

Trauma surgery and orthopaedics

73. Incision on bone, septic and aseptic

74. Closed reduction on fracture, luxation or epiphyseolysis

with osteosynthesis

75. Suture and other operations on tendons and tendon sheath

76. Reduction of dislocation under GA

77. Arthroscopic knee aspiration

Operations on the breast

78. Incision of the breast

79. Operations on the nipple

Operations on the digestive tract

80. Incision and excision of tissue in the perianal region

81. Surgical treatment of anal fistulas

82. Surgical treatment of haemorrhoids

83. Division of the anal sphincter (sphincterotomy)

84. Other operations on the anus

85. Ultrasound guided aspirations

86. Sclerotherapy etc.

Operations on the female sexual organs

87. Incision of the ovary

88. Insufflation of the Fallopian tubes

89. Other operations on the Fallopian tube

90. Dilatation of the cervical canal

91. Conisation of the uterine cervix

92. Other operations on the uterine cervix

93. Incision of the uterus (hysterotomy)

94. Therapeutic curettage

95. Culdotomy

96. Incision of the vagina

97. Local excision and destruction of diseased tissue of the vagina and the pouch of Douglas

98. Incision of the vulva

99. Operations on Bartholin’s glands (cyst) Operations on the prostate & seminal vesicles

100. Incision of the prostate

101. Transurethral excision and destruction of prostate tissue

102. Transurethral and percutaneous destruction of prostate tissue

103. Open surgical excision and destruction of prostate tissue

104. Radical prostatovesiculectomy

105. Other excision and destruction of prostate tissue

106. Operations on the seminal vesicles

107. Incision and excision of periprostatic tissue

108. Other operations on the prostate

Operations on the scrotum & tunica vaginalis testis

109. Incision of the scrotum and tunica vaginalis testis

110. Operation on a testicular hydrocele

111. Excision and destruction of diseased scrotal tissue

112. Plastic reconstruction of the scrotum and tunica vaginalis testis

113. Other operations on the scrotum and tunica vaginalis testis

Operations on the testes

114. Incision of the testes

115. Excision and destruction of diseased tissue of the testes

116. Unilateral orchidectomy

117. Bilateral orchidectomy

118. Orchidopexy

119. Abdominal exploration in cryptorchidism

120. Surgical repositioning of an abdominal testis

121. Reconstruction of the testis

122. Implantation, exchange and removal of a testicular prosthesis

123. Other operations on the testis

Operations on the spermatic cord, epididymis and ductus deferens

124. Surgical treatment of a varicocele and a hydrocele of the spermatic cord

125. Excision in the area of the epididymis

126. Epididymectomy

127. Reconstruction of the spermatic cord

128. Reconstruction of the ductus deferens and epididymis

129. Other operations on the spermatic cord, epididymis and ductus deferens

Operations on the penis

130. Operations on the foreskin

131. Local excision and destruction of diseased tissue of the penis

132. Amputation of the penis

133. Plastic reconstruction of the penis

134. Other operations on the penis

Operations on the urinary system

135. Cystoscopical removal of stones

Other Operations

136. Lithotripsy

137. Coronary angiography

138. Haemodialysis

139. Radiotherapy for Cancer

140. Cancer Chemotherapy

Cashless Facility
Cashless facility means a facility extended by the insurer to the insured where the payments, o f the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent pre-authorization approved. Most insurance companies in India provide cashless claims facility either directly or through a Third Party Administrator (TPA). Cashless facility means that a claimant does not have to pay upfront, up to available policy limits and sub-limits, to a hospital for the treatment availed.

Third Party Administrator (TPA)
Licensed by IRDA, TPAs are engaged by the insurance companies to facilitate cashless facility at empanelled hospitals. The TPAs authorize expenses for treatment and settle the charges directly with the hospitals.

Panel Hospitals
Most insurance companies have empanelled, directly or through a TPA, hospitals and nursing homes for providing cashless service to their customers. Names of these hospitals are widely publicized on the websites of the insurance companies or the TPAs engaged by them.

Health Cards
These are cards issued by an insurance company or a TPA for identification of the family members insured under a policy. Some insurance companies issue health cards with the photographs also.

Portability
A policy holder can shift his / her insurance from one insurer to another for any reason by exercising the portability option. Portability means the right accorded to an individual health insurance policy holder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan o f the same insurer, provided the previous policy has been maintained without any break.