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ƥ The terms, coverages, exclusions,

rating and underwriting practices of
Health Insurance, Personal accident &
Critical Illness vary among the
companies

ƥ The details mentioned here reflect only

the general approach of the insurers
ƥ Health Insurance provides coverage for
the medical expenses of the admissible
claims
ƥ Individual Mediclaim Policy

ƥ Group Mediclaim Policy

ƥ To cater to the varying and increasing
needs, different forms of Health
Insurance covers are available

ƥ Medical examination may be required in

some cases based on the age & Sum
Insured opted

ƥ Health insurance operates in two ways

w
  


ƥ Individuals are granted this cover

ƥ Provides cashless/reimbursement of
hospitalisaion expenses for illness /
disease / injuries sustained during the
policy period within India
ƥ The maximum liability per person
cannot exceed the individual Sum
insured
ƥ Individuals within the agegroups specified by
the insurance companies can take the policy
ƥ Normally companies put a waiting period of
one month
ƥ Family Discount is also provided
ƥ Some insurance companies grant floater
cover also for families
ƥ For Claim free renewals, insurance companies
grant cumulative bonus
 Some of the coverages provided by the
insurance companies include;

ƥ Expenses related to;

ƛ Room, Boarding expenses in the Hospital /
Nursing Home
ƛ Nursing Expenses
ƛ Surgeon, Anasthesia, Medical practitioner,
Consultant, Specialist Fees
ƛ Anaesthesia, Blood, Oxygen, Operation
Theatre Charges, Surgical Appliances,
Medicines and Drugs, Diagnostic Materials,
X- Ray, Dialysism Chemotherapy,
Radiotherapy, Cost of pacemaker and
similar expenses
ƥ Claims are admissible only when
treatment is taken in a hospital/nursing
home which satisfies the criteria as per
the policy wording
ƥ Expenses on hospitalisation for a minimum
period of 24 hours are admissible

ƥ However this time limit is not applicable to

certain treatments (for eg Dialysis,
Chemotherapy, Kidney stone removal etc.)

ƥ Pre & Post hospitalisation charges as

specified in the policy wording, are also
covered
Some of the exclusions are;
ƥ All diseases/injuries which are pre-existing
when the cover incepts for the first time
ƥ Diseases contracted during the first 30 days
from the commencement of the policy, except
those which are stated separately in the
schedule
ƥ Certain diseases like Hernia, Cataract,
Sinusitis etc are not covered during the first
year of the policy
ƥ Claims as a result of War, Nuclear weapons
materials
ƥ Cost of spectacles, contact lenses, hearing
aids
ƥ Dental treatment or surgey of any kind unless
due to accidents and require hospitalisation
ƥ Congenital diseases, AIDS, use of intoxicating
drugs, alcohol
ƥ intentional Self injury, vaccination
ƥ pregnancy, childbirth (can be covered if
maternity benefit is selected)
ƥ Schedule of the policy: The policy schedule
incorporates the following details of all the
persons to be covered, apart from the usual
details like name, address etc

ƥ Name
ƥ Age
ƥ Gender
ƥ Relationship with the insured
ƥ Occupation
ƥ Sum insured
ƥ Premium
Sum Insured & premium:

ƥ Various SI Options are available

ƥ Separate premium rates are charged for
the various age groups
ƥ The premium rates are related to the
age of the persons and the Sum insured
opted
ƥ Proposal form: Elicits a detailed information
relating to Name, address, DOB, Gender,
Relationship with the insured, monthly
income, medical conditions, previous claim
details etc

ƥ In case of adverse medical history, the

insured has to complete a detailed medical
questionnaire also

ƥ These forms are scrutinised by the panel

doctors and based on their opinion
acceptance, exclusions, terms etc are decided
  
ƥ GMC Policies are issued for group of
individuals

ƥ GMC Policy is available for any group

/association/instituition/corporate body
provided it has a central administration
body and minimum no of persons to be
covered
ƥ Coverages are same as that of Individual
mediclaim policies, with few differences
ƥ It is not permissible to issue unnamed policy
ƥ There will be no family discount, cumulative
bonus etc
ƥ Group discounts are available based on the
group size
ƥ Renewal premium is subject to bonus/malus
clause
ƥ Insurance companies now offer extensions
like maternity benefit, Preexisting disease
waiver, Waiting period waiver etc.
 !


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ƥ The purpose of Personal Accident is to

pay fixed compensation for death or
disablement resulting from accidental
bodily injury

ƥ Policy forms and rating system used by

the companies are not uniform but
follow similar approach with minor
variations
Types of disablement:

ƥ Permanent Total Disablement

ƥ Permanent Partial Disablement
ƥ Temporary Total Disablement
ƥ Permanent Total Disablement

ƛ The disablement is permanent and

irrecoverable and is absolutely total
ƛ ie, the insured is prevented from engaging
in gainful employment of any kind
ƛ Eg: Paralysis, loss of sight of both eyes,
loss of limbs
ƥ Permanent Partial Disablement:

ƛ Similar to PTD but diablement is not total

but is only partial. Eg: Loss of finger
ƛ The percentage of compensation is as per
the table mentioned in the policy schedule
ƛ For eg the table specifies that for loss of
little finger the compensation is 4% of the
SI, loss of four fingers 35% etc
ƥ Temporary Total Disablement

The disablement is total but for a

temporary period only
Weekly benefits are payable (Usually 1% of
the Sum Insured up to the specified limits and
period)
ƥ Benefit Chart

A table of benefits specifying the

amounts of compensation payable in
the event of happening of various
contingencies
Additional Benefits

ƥ Carriage of dead body

ƥ Education fund ƛ for the dependant
children
ƥ Cumulative bonus
ƥ Family discount
ƥ Medical expenses incurred in connection
with bodily injury can also be covered
on payment of extra premium
ƥ Rating:
ƛ The main factor used for PA Rating is the
occupation
ƛ The Premium differs in case of different
risk levels determined by your occupation
ƥ Risk Level I :
ƛ Administrative / managing functions,
accountants, doctors, lawyers, architects,
teachers and similar occupations
ƥ Risk Level II :
ƛ Manual labour, garage mechanic, machine
operator, paid driver (car / truck / heavy
vehicles) cash carrying employee, builder,
contractor, veterinary doctor and similar
occupations.
ƥ Risk Level III:
ƛ Workers in underground mines, electric
installations with high tension supply.
Jockey, circus performers, big game
hunters, mountaineers, professional river
rafters and similar occupations
Some of the exclusions commonly found in PA
Policies are;

ƥ Accidental bodily injury due to:

ƛ Suicidal attempts, self-inflicted injury,
pregnancy or child birth
ƛ While under the influence of liquor or
drugs:
ƛ Through deliberate or intentional, unlawful
criminal act, error or omission.
ƥ Consequential losses of any kind
ƥ War and allied perils and nuclear risks
The PA proposal form elicits information on the
following:

ƥ Personal Details - Age, height, weight,

occupation, monthly income
ƥ Physical Condition
ƥ Habits & Past times
ƥ Past claim history
ƥ Previous accidents or diseases
ƥ Selection of benefits and sum insured (The SI is
compared with the monthly income)
ƥ Declaration
 


ƥ Issued to groups

ƥ There should be a common relationship

among the persons to be insured

ƥ There should be a central point of

administration for the policy scheme
ƥ GPA Policies can be granted to groups

ƛ With Employer-Employee Relationship

( Firms, Companies etc)

ƛ Without Employer-Employee Relationship

(Associations, Societies, Clubs etc)
ƥ The coverages of GPA Policies are similar to
that of individual PA Policy

ƥ Cumulative bonus, Family discount &

Education grant do not apply

ƥ Group discounts are possible

ƥ Bonus / Malus may be applied during

renewals
ƥ


 


ƥ Critical illness policy provides protection

from the life threatening illness, which
can hamper the routine life style.

ƥ With a critical illness cover the insured

can secure his life from such
contingencies.
ƥ Critical Illness is a benefit policy which
pays the SI as lump sum amount once
the insured is diagnosed with one of the
listed critical illness . Irrespective of the
medical expenses, the lumpsum benefit
is provided
The critical Illness policy covers major illnesses
like;

ƥ Cancer
ƥ Paralysis
ƥ Coronary Artery Bypass Surgery
ƥ Major Organ Transplant
ƥ First Heart Attack
ƥ Stroke
ƥ Kidney Failure
ƥ Medical examination may be required in
some cases based on the age and the
benefit amount opted
Some of the common exclusions are;

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