| Q. Is it possible to take a cover only for my family members as I am already covered with my employer? |
A: Yes, it is possible. You would be the primary applicant,but you would not be one of the insureds.
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| Q. What do I have to carry when I go in for Cashless Hospitalization? |
A: All you need to carry for Cashless Hospitalization is your Health ID Card, a photo Identity proof (like Passport, Voter ID etc).
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| Q. What happens to our Floater cover limit after a claim? |
| A: The Floater limit reduces to the extent of the claim every time a claim is made by any of the, family members covered under the floater. However, the next year the limit is restored back to its original value. |
| Q. Can I get hospitalized in any other town |
A: Yes, you can get hospitalized in any town in India. Cashless service is available pan India in all the network hospitals of the insurer. The list of hospital network is provided alongwith the policy. For all hospitals which are not in the network list you will have to pay first and then seek a reimbursement from the insurer. |
| Q. What will happen if I am hospitalized and my policy lapses? |
A: Your hospitalization expenses will be covered as long as the event that triggered your hospitalization occurred during the policy period. |
| Q. After the age of 60, can I renew the same policy? if yes for how long? |
| A: Yes, you can renew your policy lifelong. |
| Q. Are there any bonuses available in the event of no claims? |
A: Yes, at the time of renewal, most companies offer a discount up to a certain percent if no claim was made in the previous year. Insurers either offer a percent of discount on renewal premium or enhance the Sum Insured by a percent. |
| Q. Are there any waiting periods when my expenses will not be settled, in case of a contingency? |
A: Any health insurance policy has a 30 day waiting period starting from the policy start date, when any hospitalization charges would not be settled. However, this is not applicable to any emergency occurring due to an accident. As long as the insured has been admitted for 24 hours, the claim will be settled in case of an accident, as there is no waiting period clause. Insurers also apply a waiting period of 1-2 years for certain old age diseases like cataract, hysterectomy, hernia etc. These diseases are specified in the policy given by the insurer. |
| Q. What is a PreExisting disease? |
A: A PreExisting disease is any disease that you or your family member is already suffering from at the time of applying for the policy for the first time e.g., Hypertension, Diabetes. |
| Q. Are any PreExisting diseases covered? |
A: Most insurers cover PreExisting diseases from 5th renewal onwards if you continuously renew the policy with the same insurer. |
| Q. Are maternity expenses covered? |
| A: Some companies cover maternity expenses after certain waiting period. Most policies do not cover. Check with this broker who can help you identify those companies. |
| Q. Is homeopathy/ayurvedic/yunani treatment covered? |
| A: Yes, some companies cover these types of treatments. Check with this broker who can help you identify those companies. |
| Q. In case my family member or me undergo treatment at our home under nursing care, is it covered? |
| A: Treatment received at home is covered only if the condition of the patient is such that moving the patient to the hospital is not medically advised or the hospital refuses admission citing unavailability of beds. |
| Q. What if the hospitalization is for less than 24 hours (e.g., For kidney stone removal)? |
| A: Insurers cover all advanced technological surgeries such as kidney stone removal, catheterization, chemotherapy etc. under day care treatment and do not insist on 24 hours hospitalization in case of these procedures. The list of such procedures is mentioned in the policy issued by the insurer. |
| Q. Are accidental injuries covered? |
| A: Yes, this policy covers accidental injuries, which require hospitalization for a period of at least 24 hours or more, from the first day of the policy coverage period. |
| Q. Is a medical checkup compulsory for enrolling? |
A: Individuals and family members who are more than a certain age are required to submit medical tests before the policy is accepted by the insurer.
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| Q. Who will bear the cost of the medical check-up? |
A: You will have to pay the cost for the tests taken to initiate or continue your coverage |
| Q. How do I get income tax benefit? |
| A: As per government regulation, any premium payment towards medical insurance is deductible from the total income for tax calculation purpose under section 80 D. The maximum amount deductible from the total income is Rs.15,000/-. |
| Q. I am already covered by my employer. Why do I need to take this policy? |
| A: Your employer will cover your medical expenses only as long as you are in his services. Tomorrow, you may change you job, retire, or even start something on your own - in all such cases you and your family will be stranded if a medical emergency arises and you have not arranged for an alternate health insurance policy. Since the premiums increase as the age increases, it might be a better idea to commence the cover right now. |
| Q. Who can be covered under the policy? |
| A:Any of the immediate family members of the primary applicant(eg., Spouse, Dependent father and mother, son and daughter, brother and sister (upto a certain age)) can be covered under a health insurance policy. |
| Q. Why do you need health insurance? |
| A:Today's lifestyle is such that people are more prone to repetitive ailments, disorders and as such lack of stamina. Apart from competing with growing technology, Man also has to compete with his health conditions. It's not always possible to, 'Eat Healthy and Think Better'. Health costs are also increasing by 20%, on an annual basis. Considering all this, it makes economical sense to invest in a superlative health insurance plan. |
| Q. What is a deductible? |
| A:A "deductible" is a specific rupee amount that the insured would need to pay from his pocket, before availing any benefits from the health insurance policy. |
| Q. What is a co-payment? |
| A:A "co-payment" or "co-pay" is a specific charge that your health insurance plan may require you to pay for a specific medical service or supply. Insurance company then pays the remainder charges. |
| Q. What is co-insurance? |
| A:Coinsurance is the amount that you are required to pay for a medical claim, apart from any co-payments or deductible. For example, if your health insurance plan has a 20% coinsurance requirement (and does not have any additional co-payment or deductible requirements), then an Rs1000 medical bill would cost you Rs200, and the insurance company would pay the remaining Rs800. |
| Q. What is the difference in a co-pay and co-insurance? |
| A:Co-insurance is the portion of costs that are shared between the insured and the insurer. It is common for an insurance company to pay 80% with the insured being responsible for the remaining 20%. Co-pay is a predetermined amount of money that the insured pays out for certain services. For example, if you have a Rs200 co-pay on doctor's visits, you would pay the doctor Rs200 for every visit and the insurance would pay the rest of the doctor's fee for that visit. Special services, like x-rays or lab work, aren't usually covered under the co-pay for the doctor's visit. |
| Q. Is co-payment part of the annual deductible? |
| A:No, most insurance policies that have co-pays and deductibles handle doctor's visits and hospital stays separately. You have to read the terms of your policy, but in most cases, co-pay applies to the doctor's visit and the deductible applies to hospitalization or other healthcare services. It is quite likely that in one plan, you will have deductible, co-pay as well as co-insurance. |
| Q. Does a plan cover any PreExisting diseases? |
| A:PreExisting diseases, as the name suggests are diseases a person had before obtaining the insurance policy. Some health insurance plans will cover PreExisting Diseases after a certain period, while others may completely exclude them. |
| Q. What is critical care insurance policy? |
| A:A new and first of its kind, a health insurance plan called critical care provides lump sum benefits on diagnose of critical diseases/illnesses. It's targeted towards health-conscious individuals. Some insurance company's critical plan also provides an additional cover against personal accident, permanent total disablement and a second opinion on the first diagnose of the critical illness (pls refer the product brochure for more details on coverage, terms and exclusions). An individual opting for this should not have suffered from any per-existing disease, 90 days prior the policy start date. |
| Q. How do I select the appropriate cover for me? |
| A:The appropriate cover amount depends upon the certain factors such as, your age, PreExisting diseases, financial status, lifestyle, the frequency at which you use the cover, your need for a basic cover or comprehensive cover, short tem cover or long term cover etc. If you want us to help you on selecting an appropriate cover for you, Pls do not hesitate to call/chat/email us. |
| Q. Can I get a cover as soon as I buy health insurance policy? |
| A:No, normally there will be a waiting period of 30 days before you can actually start using the benefits of the plan. However, from second year onwards, this is not applicable. |
| Q. If I have to buy a policy for my family of more than four members, do i need to buy an additional one? |
| A:For a family of 4 people, most insurance companies give you the family plan coverage, but for a family of more than four, there are some companies that give you cover. Please call us / email us. We would be happy to help you with this. |
| Q. Does a higher cover mean better protection? |
| A:Rising medical cost is a major deterrent, and thus, a higher cover would guarantee you a better protection. "It simply implies, the more you take, the better you get". |
| Q. Is it necessary to have a medical check up before buying a policy? |
| A:Yes, most of the policies would need a medical check up report, not older then 180 days. |
| Q. What is the procedure for availing the Mediclaim benefits? |
| A:Use health identity card at any of the network hospitals of the insurance companies and avail cashless service. Contact TPA on the number, given by the insurance company or mentioned in the health card, fax/submit the required docs for identification and authorization, obtain approval of identification, on network/non-network hospitals from TPA. After getting an approva, customer can avail the treatment. |
| Q. What are the documents required for filing a claim? |
| A:All the original bills from doctors, chemists, all original receipts, doctor's certificate, hospital card, lab test reports, surgeon's bill, note prescribing the type of operation performed etc, along with complete claims forms needs to be submitted, for settlement of a claim. |
| Q. Who can be covered under the policy? |
| A:Any of the immediate family members can be covered under a health insurance policy . i.e., Spouse, Dependent father and mother, son and daughter, brother and sister (upto a certain age) of the primary applicant. |
| Q. How much time does it take to settle the bills? |
| A:It takes about 15-25 days to settle the claim, depending upon the relevant claim documents submitted. |
| Q. Whether I should pay first for hospitalization? |
| A:Only in case, if you are admitted to a non-network hospital, you have to settle the claim first and the same will be reimbursed to you later, by the insurance company.(pls check a list of network hospitals given at the time of purchase of the policy) |
| Q. What is TPA? DO I need to approach a TPA for settling my claims? |
| A:TPA is a Third Party Administrator. A TPA is a specialized health service provider rendering a variety of services like networking with hospitals, arranging for hospitalization, claim processing and documentation. All insurance claims are settled by third party administrator. In case of hospitalization, the charges would be directly paid to the hospital, for that you would need to call on a help line number of a TPA and they will also arrange for cash less facility. This number will be given to you at the time of purchase of the policy. |
| Q. How to prevent rejection of claims? |
| A:Only claim for hospitalization, which confirms existence of an illness/ailment, which needs hospitalization. Make sure you declare all the PreExisting diseases at the time of applying for a policy. And the best way to avoid rejection of a claim is to read the policy wordings very carefully. |
| Q. What is a no-claim bonus? |
| A:If you do not claim, during your period of policy, then an insurance company can give you a bonus of around 10-15% on the premium, if you re-issue a policy with them. The percentage of discount will vary among various insurance companies. |
| Q. Why should I buy my policy from you, when I can buy from other Insurance company? |
A:www.easyinsuranceindia.com, site owned and operated by ICM Insurance Broking Pvt Ltd, is one of the first websites in India to offer the customer, comprehensive list of all the Insurance products in one website. It is India's premier website to offer comparisons of various types of insurances from a gamut of insurance companies. By combining our experience and knowledge of Insurance, we are able to offer our customers,
- Comparison of plans by product from multiple insurance companies for individuals, families and small businesses.
- Comparison of plans by pricing from multiple insurance companies for individuals, families and small businesses.
- Easy accessibility of various insurance products. You need not spend money / time visiting the insurance company and you need not spend money on calling your insurance agent, you can save money and your energy by comfortably sitting at home, and compare-buy-print your policy online from our website.
- Manage insurance portfolio online on our website, to keep a track of your policies. You will also receive reminder e-mails/SMS on renewals.
- Customer Service is what we are committed to. Our knowledgeable representatives will help you make the most of your money with professional, unbiased and honest advice on choice of a plan that suits your needs and assist you at the critical juncture on claims.
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| Q. How best Do you offer the prices? |
| A: Whether you buy from www.Easyinsuranceindia.com, your local agent, or directly from the health insurance company, you'll pay the same premium for the same plan. So by logging on www.Easyinsuranceindia.com, you can enjoy the advantage and convenience of comparative shopping on click of a mouse for your insurance plan. We are specialized intermediary especially licensed to represent the customers, not the insurance company. So, we can suggest objectively the best policy by looking at policies offered by many different companies based on your need. |
| Q. What is a TPA? |
| A:Third Party Administration (TPA) is a service given to a Mediclaim policyholder by providing cashless facility for all hospitalizations that come under the scope of his/her Mediclaim policy. |
| Q. What are the benefits of TPA to a policyholder? |
| A:The policy holder will have full freedom to choose the hospitals from the respective TPA's empanelled network and utilize the services as per his choice. For every hospitalization, the policyholder should be aware that the treatment he is to undergo is covered under his policy or not. If covered, then he can seek cashless facility at any of the respective TPA's Network hospitals. During the time of Emergency Hospitalization, the policyholder or his relative can flash the Photo ID Card of the policyholder and gain admission into any of the network hospitals. No amount is to be paid at the time of discharge too. Thus, the Individual does not have to run around for arranging money to pay for the hospital expenses. TPAs have ambulance referral, surgeon's referral and specialist's referral and the policy holder can easily avail these services. |
| Q. What are the facilities offered by a TPA? |
| A:1 A 24 X 7 assistance to all policy holders through toll free number of the TPA 2 Online assistance during hospitalization and filing of claim documents 3 Assistance in providing Ambulance Services during Emergency 3 Enrollment Card against your policy, which would give you access to TPA services. 4 Cash Less service facilitation at network hospitals up to limit authorized by Mediclaim/Hospitalization Insurance 5 Claims Processing and Reimbursement for non-network hospitals 6 Other services as defined by your Employer/Insurer. |
| Q. What do you mean by Network /Non-network Hospitalization? |
| A:A Hospital, which has an agreement with aTPA for providing Cashless treatment, is referred to as a 'Network Hospital'. Cashless facility is provided ONLY at the network hospitals. Non-network hospitals are those who have not agreed to the TPA terms and conditions and any policyholder seeking treatment in these hospitals will have to pay for the treatment and later claim as per normal procedure. |
| Q. What is Cashless access/Cashless Facility? |
| A:This means you can walk into any of the network hospitals across the country and get treated without having to pay for your hospital bills. If you do not get admitted to a networked hospital, your expenses will be reimbursed by the insurance company only on receipt of complete documents from you. |
| Q. How do I avail of Cashless Facility? |
A:Cash Less facility is available only in network hospitals. In case the patient wants to be referred to a network hospital the TPA needs to obtain the following documents from the patient before issuing a preadmission authorization for cash less facility:
- Original first prescription of the doctor referring the hospitalization, complete details like symptoms and diagnosis on his/her prescription letter head.
- Hospitalization Form in the given format duly filled
- Details of previous policies : if the details are not already available with TPA except in case of accidents , in case information available is not complete in the hospitalization form or if the history of the disease is not confirmed, a preadmission authorization cannot be issued for cash less facility. In such a case, if the patient is admitted in a network hospital, treatment will be same as in case of a non-network hospital. The doctor must clearly mention in the history sheet - the record of history of the disease, relation to preexisting diseases like hypertension, diabetes etc if any and history of the same.
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| Q. What documents should one obtain before discharge from the hospital in case of cash less facility availed? |
| A:All bills in original and a discharge certificate are to be left with the hospital providing cashless treatment. The patient has to countersign all bills and fill the claim form and also leave the same with the hospital at the time of discharge. A copy of the bills & Discharge Summary can be carried by the patient for his records and for submission along with Pre & Post Hospitalization bills. |
| Q. What documents are needed for processing claims if the treatment has been done in a non-network hospital or in a network hospital where cash less facility was not granted/availed? |
| A:Following documents are required for processing the claims on reimbursement basis: 1. Claim Form properly filled and signed by the claimant 2. Discharge Certificate from the hospital 3. All documents pertaining to the illness starting from the date it was first detected i. Bills, Receipts ii. Cash Memos from hospital supported by proper prescription iii. Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics. Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt iv. Attending doctor's/consultant's/specialist's/anesthetist's bill and receipt, and certificate regarding diagnosis v. Certificate from the attending medical practitioner/surgeon that the patient is fully cured b. Details of previous policies : if the details are not already with TPA except in the case of accidents. |
| Q. When will my claim be reimbursed? |
| A:The claim will be reimbursed after receipt of complete documentation from the client. |
| Q. Can I get Cash less facility/Reimbursement in the case of PreExisting diseases? |
| A:PreExisting diseases are excluded in Mediclaim Policy. TPA's doctor panel will verify/check the inception of disease based on your medical records and in case the disease has an origin before the inception of the policy, then your claim is not payable, as per the policy. |
| Q. Can I get Cash less facility/Reimbursement within 30 days of policy commencement? |
| A:Mediclaim policies have a waiting period of 30 days. Only accidents if occurred during the first 30 days of the policy are covered. Any other disease is not payable. |
| Q. How do I get a list of network hospitals of TPA? |
| A:Along with your ID card, you will get a kit comprising of a Guide Book and List of Network Hospitals. You can also download the list from the respective TPA's website. |
| Q. During the course of my treatment, can I change the hospitals? |
| A:Yes it is possible to shift to another hospital for reasons of requirement of better medical procedure. However, this will be evaluated by the TPA on the merits of the case and as per policy terms and conditions. |
| Q. Can I get outpatient treatment using my TPA Card? |
| A:No. The TPA Card is issued to you against your mediclaim policy which only covers hospitalization expenses. The outpatient/domiciliary expenses pertaining to the treatment of disease which is the cause of hospitalization is however covered (Please see Pre & Post Hospitalization benefits) |
| Q. I am not keen to avail of Cash less facility. Can I go in for reimbursement? |
| A:Yes. Under the Mediclaim Policy, you can opt for Cash Less as well as Reimbursement. We would advise that in case you are taking treatment from a network hospital, then you should avail of the Cash less facility. This will give you the financial advantage of not paying for your hospital treatment and also gives you more cushion to meet your post-hospitalization expenses. |
| Q. What is the benefit of carrying a health card? |
| A:The benefit of carrying the Health Card is that you and your family members get access to the cash less facility from the TPA's network of hospitals. This means you can walk into any of the networked hospitals across the country and get treated without having to pay for your bills first and then claim form us. If you do not get admitted to a networked hospital, your expenses will be reimbursed within 7 days of receipt of complete documents from you. Also in the event of any unforeseen accident a third party can identify your Insurance Company and your family can be intimated. |
| Q. What is Health Insurance/Mediclaim? |
| A:Health Insurance/Mediclaim is protection against medical costs. A health insurance policy is a contract between an insurer and an individual /group in which the insurer agrees to provide specified health insurance cover at a particular premium. The health insurer usually provides either direct payment (cashless facility) or reimburses the expenses associated with illnesses and injuries.Mediclaim Insurance is a cover, which takes care of the hospitalization expenses subject to maximum sum insured of the Insured in respect of the following situations: A. In case of a sudden illness. B. In case of an accident. C. In case of any surgery, which is required in respect of any disease which has arisen during the policy period? |
| Q. What are the salient features of this policy? |
| A:Though the features may vary from insurer to insurer, some basic features are: 1 Reimbursement for Hospitalization due to illness/disease/ surgery. 2 Reimbursement for Domiciliary Hospitalization expenses in lieu of Hospitalization. 3 Pre-hospitalization expenses 4 Post-hospitalization expenses 5 Ambulance Charges 6 Cashless Access 7 Income Tax Benefit etc. |
| Q. What is covered under Hospitalization Benefit? |
| A:1 Expenses on Hospitalization for a minimum period of 24 hours. 2 In case of treatments like Dialysis, Chemotherapy, Lithotripsy, Radiotherapy, Eye surgery, Dental Surgery, Tonsillectomy, D&C taken in Hospital/Nursing Home, the time limit of 24 hours is not applicable. |
| Q. What are the circumstances under which the condition of minimum 24 hrs hospitalization does not apply? |
| A:This condition will not apply in the following cases: 1 the treatment is such that it necessitates hospitalization and the procedure involves specialized infrastructural facilities available in Hospitals. 2 due to technological advances hospitalization is required for less then 24 hours only. |
| Q. What are the expenses covered under Hospitalisation Expenses? |
| A:Hospitalization expenses incurred as an in-patient in a Hospital include: 1. Room, Boarding Expenses as provided by the Hospital/Nursing Home. 2. Nursing Expense. 3. Fees of Surgeon, Anesthetist, Medical Practitioner, Specialists, Consultants. 4. The cost of anaesthesia, diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs, operation theatre charges, Dialysis, Chemotherapy, Radiotherapy and similar expenses. |
| Q. What is Domiciliary Hospitalization? |
| A:Domiciliary Hospitalization means medical treatment for a period exceeding three days for such illness/disease/injury which in the normal course would require care and treatment at a Hospital/Nursing Home but actually taken whilst confined at home in India under any of the following circumstances, namely: i) The condition of the patient is such that he/she cannot be removed to the Hospital/Nursing Home or ii) The patient cannot be removed to Hospital/Nursing Home for lack of accommodation therein |
| Q. What do you mean by Pre and Post hospitalization? |
| A:Relevant medical expenses incurred before and after hospitalisation for a specified number of days. Relevant medical expenses means expenses related to the treatment of the disease for which the insured is hospitalised. |
| Q. For how many days would the pre and post hospitalization expenses be covered? |
| A:The period varies according to the insurer and the plan opted for. Insurer Pre hospitalization/Post hospitalization. It could be either 30 or 60 days. |
| Q. What is meant by Donor Expenses? |
| A:All hospitalization expenses incurred by the donor for donating an organ (excluding the cost of the organ) to the insured during the course of an organ transplant. |
| Q. How much is the sum insured? |
| A:Sum insured is the amount of coverage taken by the insured by paying the Premium plus the Cumulative Bonus accumulated in the policy, if available. |
| Q. What is Family Floater and what are its advantages? |
| A:Family Floater is a policy wherein the entire family of the insured, comprising of insured, spouse and two dependent children, is covered under single sum insured. The advantages of such a policy are: 1. All members of the family (as defined above) can be covered under one policy. 2. Single Premium is payable for the entire family. 3. The amount of Sum Insured floats over the entire family i.e., the limit can be used by any member of the family. 4. One does not have to keep a track of renewals for different members; a single renewal date is to be remembered. |
| Q. Is there an Income Tax exemption on the premium? If yes, under which section and what is the Income Tax exemption limit? |
| A:Yes, Premium paid for mediclaim policy is eligible for tax deduction under section 80 D of the Income Tax Act, subject to the condition that the premium amount is paid by cheque/DD by the customer from his bank account. As per current IT rules you can get an exemption up to a maximum sum of Rs.15000 from your taxable income under Section 80-D for Health Insurance Premium paid for self, spouse, dependent children and dependent parents and Rs 20000 if the policy includes senior citizens whose ages is above 60 yrs. Check for the current updated information with your tax consultant. |
| Q. What is Cumulative Bonus? |
| A:An increase in the Sum insured by a specified percentage 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 C.B. |
| Q. If I have accumulated cumulative bonus on my policy for the last three years and I have a claim in the fourth year, will I lose my C.B.? |
| A:In this case the increased percentage will be reduced by 10% of sum insured at the next renewal. However, the basic SI will be maintained and will not be reduced. |
| Q. Do I get a discount on renewal of the policy with the same company? |
| A:Some companies offer a renewal discount of 5% of renewal premium if there are no claims in the expiring policy period. |
| Q. What is the First 30 days Exclusion? |
| A:Any expenses on hospitalization/domiciliary hospitalization incurred during first 30 days from the date of commencement of insurance cover, except in case of injury arising out of accident, are not payable. |
| Q. What are first year/second year exclusions? |
| A:During the period of insurance cover, the expenses on treatment of certain diseases such as cataract, hernia, piles, sinusitis, benign Prosthetic Hypertrophy, Hysterectomy for Menorrhegia or Fibromioma etc. for specified periods (Please refer to your policy document for details) are not payable if contracted and/ or manifested during the currency of the policy. |
| Q. Enlist some of the important exclusions under mediclaim policy. |
| A:Some general exclusions under this policy are: 1 PreExisting diseases i.e., diseases which are already existing before the inception of the policy 2. Any disease contracted during the first 30 days of inception of policy except in case of injury arising out of accident 3. 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. 4. Injury or Diseases directly or indirectly attributable to War, Invasion, Act of Foreign Enemy, War like operations. 5. Cosmetic, aesthetic treatment unless arising out of accident. 6. Cost of spectacles, contact lenses and hearing aids 7. Dental treatment or surgery of any kind unless requiring hospitalization 8. Charges incurred at Hospital or Nursing Home primarily for diagnostic, x-ray or laboratory examinations,without any treatment. 9. Naturopathy or other forms of local medication 10. Pregnancy & childbirth related diseases 11. Intentional self-injury/injury under influence of alcohol, drugs 12. Diseases such as HIV or AIDS 13. Expenses on vitamins and tonics unless forming part of treatment for disease or injury as certified by the attending physician. 14. Convalescence, general debility, run-down condition or test cure, congenital external diseases or defects or anomalies, sterility, venereal disease. |
| Q. Can a person have more than one Health policy? |
| A:Yes. But each company will pay its rateable proportion of the loss, liability, compensation, costs or expenses. E.g., If a person has Health Insurance from company X for Rs. 1 Lac and Health Insurance from company Y for RS. 1 Lac, then in case of a claim, each policy will pay in the ratio of 50:50 up to the SI. |
| Q. Can I cancel my policy and if yes will I get my premium back? |
| A:Yes, the insured can cancel the policy at any time. In such a case, the company shall allow a refund of premium at company's short period rate(given below) provided no claim has occurred during the policy period up to cancellation. Period of cover up to Rate of premium to be charged 1 month ¼ of the annual rate 3 months ½ of the annual rate 6 months ¾ of the annual rate More than 6 months Full annual rate |
| Q. What are the medical tests that I need to undergo to enroll myself? And who will bear the cost? |
| A:Medical tests required are Blood/Urine sugar, Blood Pressure, ECG and Eye check up including retinoscopy. The cost has to be borne by the insured. |
| Q. Will I get the entire amount of the claimed expenses? |
| A:The entire amount of the claim is payable, if it is within the Sum Insured and is related with the in-house treatment as per policy conditions and is supported by proper documents, except the expenses which are excluded |
| Q. Can any claim be rejected or refused? |
| A:Yes, the claim, which is not covered under the policy conditions, can be rejected. In case you are not satisfied by the reasons for rejection, you can represent to the insurer within 15 days of such denial. |
| Q. In case of part settlement can an insured claim for the balance amount? |
| A:Normally, part payments are made due to deficiency of documents or for expenses which are not covered under the policy. In case of the former if the requisite documents are made available, the claim may be considered. |
| Q. How can I check the status of my claim? |
| A:You can call the helpline number of your TPA or check on their site using your Policy number or member id. |
| Q. How does one get Reimbursement for pre and post hospitalization expenses? |
| A:The Mediclaim Policy allows reimbursement of medical expenses incurred towards the ailment/ disease for which hospitalization was necessitated prior to hospitalization and up to a certain number of days after discharge as per the limit specified in the policy. For reimbursement, send all bills in original with supporting documents along with a copy of the discharge summary and a copy of the authorization letter to your TPA. The bills must be sent to the TPA within 7 days from the date of completion of treatment. The insured must also provide the company/TPA with additional information and assistance as may be required by the company/TPA in dealing with the claim. |
| Q. What is the procedure to get Reimbursement in case of planned hospitalization? |
| A:1 Inform TPA about the planned hospitalization. 2 Get admitted into the hospital as planned. 3 At the time of discharge, settle the hospital bills in full and collect all the bills, documents and reports. 4 Lodge the claim with TPA for processing and reimbursement by duly filling in the claim form & enclosing all original bills/vouchers/receipts. |
| Q. How does one get Reimbursements in case of treatment in non- network hospitals? |
| A:In case of treatment in a non-network hospital, TPA will reimburse you the amount of bills subject to the conditions of the policy taken by the insured. The insured must ensure that the hospital where treatment is taken fulfils the conditions of definition of Hospital in the Mediclaim policy. TPA should be contacted within 7 days from the time of admission with the following documents in original: 1 Claim Form duly filled and signed by the claimant 2 Discharge Certificate from the hospital 3 All documents pertaining to the illness starting from the date it was first detected i.e., Doctor's consultation reports/history 4 Bills, Receipts, Cash Memos from hospital supported by proper prescription 5 Receipt and diagnostic test report supported by a note from the attending medical practitioner/surgeon justifying such diagnostics. 6 Surgeon's certificate stating the nature of the operation performed and surgeon's bill and receipt 7 Attending doctor's/consultant's/specialist's/anesthetist's bill and receipt, and certificate regarding diagnosis 8 Certificate from the attending medical practitioner/surgeon that the patient is fully cured 9 Details of previous policies if the details are not already with TPA except in the case of accidents In case information is not complete in the hospitalization form or if the history of the disease is not confirmed, a preadmission authorization cannot be issued for cash less facility. In such a case, if the patient is admitted in a network hospital, treatment will be same as in the case of a non-network hospital. The doctor must mention in the history sheet - the record of history of the disease, relation to preexisting diseases like hypertension, diabetes etc if any and history of the same. |
| Q. What is the information one needs to furnish while intimating a claim? |
| A:The following information needs to be furnished while intimating a claim: 1 Name of Insured person who is sick or injured 2 Nature of Sickness/Accident 3 Contact Numbers 4 Policy Number (as reflecting on the Health Card) 5 Date & Time in case of accident, commencement date of symptom of disease in case of sickness 6 Location of accident |
| Q. What if I don't remember my Card Number and Policy Number and I am in an emergency situation? |
| A:In case you are in an emergency situation, TPA can search your details based on the following: Name, Address, Date of Birth Insurer Underwriting Office Code. |
| Q. Are there any restrictions on the hospital where the treatment should be taken? |
| A:There is no restriction on the hospital where treatment should be taken. The treatment can be taken in any hospital where you are visiting. However, there are some minimum qualification such as number of beds in the hospitals. It is advisable in pre planned hospitalisation, the insured informs the company who will direct them to a Network Hospital in the same locality. |
| Q. Is the sum insured mentioned under each category applicable to all members travelling on the policy and is there any restriction on number of claims? |
| A:The sum insured as mentioned in the policy schedule is for each travelling member. There is no restriction on the number of claims per person in the policy period. |
| Q. What are the two types of claim settlements? |
| A:Reimbursement & Cashless settlement. |
| Q. What do you mean by Cashless claim settlement? |
| A:The insurance company will pay up to 100% of the claim to the hospital in case of hospitals in the preferred network (subject to deductibles under the policy conditions). This will be applicable for all inpatient claims provided the same is admissible under the policy. Some expenses like registration charges, other items like non prescribed medicines will not be covered. |
