Health Insurance FAQs about Claims

You can claim medical expenses incurred 30 days before and 60 days to 90 days after hospitalization, provided they are related to the ailment/accident for which you were hospitalized. Such expenses are termed as pre and post hospitalization.

No, you cannot.

Typically, there is a waiting period of 30 days, within which no claims by the insured are entertained by the insurer. This waiting period may vary by company. Your best policy will be to read your policy document carefully and clarify the matter with your insurance agent.

There is no limit to the number of claims per annum but there is a limit to the amount that you can claim in a year. Usually, the maximum amount that you can claim in a year is limited to the sum insured. However, special plans that provide surgical benefits and daily hospitalization cash allowance have restrictions on the amount you can claim per annum.

Yes, you can but there are certain conditions. Such claims are entertained only if the condition of the patient is such that she/he cannot be moved to the hospital or there is no bed available in any of the hospitals. Furthermore, treatment must be provided comparable to that at a hospital or a nursing home. Such claims are known as domiciliary hospitalizations.

The limit of domiciliary hospitalization expenses claims are usually pegged low and not entertained at all for certain diseases, such as asthma, bronchitis, diabetes, epilepsy, etc.

Yes, your health insurance policy is valid all over the country.

No, you cannot claim expenses for a cataract operation in the first year of the policy. Most insurers have a set of specific illnesses or ailments for which they will not provide cover in the first two years from the commencement of policy; however these would be covered from the third or fourth year onwards.

The exclusions include:

• Arthritis
• Benign prostate hypertrophy
• Cataract
• Dialysis required for chronic renal failure
• Dilatation & curettage
• Fistula in anus
• Gastric and duodenal ulcers
• Gout
• Hernia
• Hydrocele
• Hysterectomy unless because of malignancy
• Joint replacement (unless due to accident)
• Myomectomy
• Piles
• Rheumatism
• Sinusitis and related disorders
• Skin and all internal tumors / cysts / nodules / polyps of any kind, including breast lumps, unless malignant / adenoids and hemorrhoids
• Stone in the urinary and biliary systems
• Surgery on tonsils and sinuses 

If you and your wife are covered under a group plan by your employer, maternity benefits may be covered. Do not forget to check up on this with your HR department. However, if you have purchased an individual health care plan, you will not be able to claim maternity benefits. 

Usually, the policy would cease in the event of a claim. However, certain insurance plans offer to cover the insured for the remaining critical illnesses, at a lower sum assured and a revised insurance premium.

A health insurance policy would not cover a pre-existing disease in the first year of cover. However, they would be covered after three to four years of continuous renewal with the same insurer.

Expenses incurred at a hospital or a nursing home for diagnostic purposes such as X-rays, blood analysis, ECG, etc. will be reimbursed if they are consistent with or incidental to the diagnosis and treatment of the ailment for which the policy holder has been hospitalized. In any other scenario, the insurer will not entertain claims.

Yes, all insurance companies reimburse expenses even if the insured does not use the network hospital.

There are no charges to the insured for using a network hospital.

However, a few insurance companies offer a discount of up to 6 per cent in certain cases if the insured chooses not to use the services of a Third Party Administrator i.e. the cashless facility.

Certain insurance companies ask the insured to bear a certain proportion (10 per cent to 20 per cent) of the expenses for not utilizing a network hospital.

Bonus for each claim free year

The sum insured increases progressively by five per cent in respect of each claim free year of insurance, subject to a maximum accumulation of 10 claims-free years.

In the event of a claim, if the insured has earned any cumulative bonus, the increased sum insured will be reduced by 10 per cent at the time of renewal. However, the basic sum insured will be maintained at all times.

Free medical check up

The insured is entitled to reimbursement of the cost of medical check-up once at the end of a block of every four or five claims-free years. The reimbursable cost will be restricted to one per cent of the average sum insured during the block of four or five years.

Typically, the insured can make a claim if her/his hospitalized stay is for over 24 hours. However, for certain treatments, such as dialysis, chemotherapy, eye surgery, etc, the stay could be less than 24 hours.

Yes.

Although one can make a claim for the full sum insured, there are limits and sub-limits under the larger expense categories. For example, some insurers have restricted room rent to 1 per cent of the sum insured per day, subject to a maximum of Rs. 5,000 per day.

Further, there are limits for medical treatments as well. For example, the maximum amount reimbursed for a cataract operation is limited to Rs. 20,000 for each eye.

If the insurance limit i.e. the sum insured is exhausted in a particular year due to large medical expenses, the insurer is not liable to bear/reimburse the insured for any further expenses. 

An ailment for which a claim has been made already does not become a pre-existent disease if there is no break in the term of the insurance policy and it is renewed within the renewal date. However, the ailment becomes a pre-existent disease and exclusions will apply in the event there is a break in the term of insurance (up to 7 days break is allowed under certain conditions; although it could vary by company). 

The claim amount is paid to the nominee of the insured.

If no nominee has been assigned under the policy, 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 legal heirs of the deceased. 

In case of planned hospitalization, insurers require the first prescription with the details of the case history indicating following details:

• Provisional diagnosis or reason for getting admitted in hospital
• Proposed date of admission
• Approximate expenses
• Name of the hospital and consultants
• Approximate duration of stay at the hospital
• Attached doctor's prescription with admission note

The above documents need to be delivered to the TPA/insurer at least 72 hours before admission.

The above-mentioned procedure could vary by company. It is therefore important that you refer to your policy details carefully.

No, a part of the bill will have to be borne by the insured if it consists of the inadmissible amounts that are listed by the insurer. 

The liability for paying the hospital will be on you. However, you the insurance company will reimburse the admissible amount.