Insurance I

Session 15

Health Insurance: Coverage, Exclusions, Claims Settlement. Group Mediclaim and Overseas Mediclaim

INTRODUCTION TO HEALTH INSURANCE

Available in India within the framework of general insurance Most common product under this category: Mediclaim (a

brand name that has become generic)

Reimbursement based hospitalization benefit scheme

Other products: Critical Illness Policy, Specific Conditions

Coverage (like diabetes, cancer etc.)

Individual and group cover
In most cases it is an annual policy, subject to renewal by

mutual agreement between the insured and insurer

NEED FOR HEALTH INSURANCE

More than 80% of the health expenditure in India is private Most of this flows directly from the households to private (for-

profit) health-care hospital

Government or state-based systems cover a small percentage

of the population (CGHS, ESI, railways, armed forces, public sector undertakings etc.)
About 30 million employees are covered under some

employer-managed health schemes

Certain schemes run by govt. / NGOs for BPL families Jan

Arogya Bima Yojana

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COVERAGE
Reimbursement of hospitalization/ domiciliary hospitalization

expenses
Domiciliary where treatment is for more than 3 days, patient

is critical or there is lack of accommodation,

Hospitalization for at least 24 hours Covers disease/ accidental injury Room rent, nursing charges, surgeons fees, consultants fees,

OT charges, cost of medicines and diagnostic charges like MRI, CT Scan, X-Ray etc.
Pre-hospitalization expenses for 30 days

Post-hospitalization expenses for 60 days

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EXCLUSIONS
Pre-existing disease in case of inception for the first time Diseases during first 30 days except accidental injuries Expenses incurred in case of first year diseases

Cosmetic surgery, plastic surgery (except necessitated by

accident)
Vaccination, inoculation etc. AIDS Naturopathy Lens, specs, hearing aids

CLAIMS SETTLEMENT
REIMBURSEMENT

For treatment in non-network hospitals, payments must be made up-front to the hospital
Reimbursement of the expenses on submission of the necessary documents

CASHLESS CARD

In all network hospitals, the cashless facility can be availed Call the 24 hour help-line to register the details of hospitalization

Mention your ID number for easy access to your policy details

FAMILY FLOATER
A comprehensive Health Insurance policy that

ensures health cover for the entire family

Affordable premium Floater benefit Lets you share the entire sum insured among the

family members covered under the policy, without any individual upper limits.

GROUP MEDICLAIM
Available to corporate, associations, institutions etc. Provided they form the minimum number of persons Group not to be formed for solely taking this cover Individual members may enter or exit the group No refund of premium in case of a member leaving the group Premium to be collected and remitted by the head of the group A complete list of the group members to be provided Individual health checkup is not required

OVERSEAS MEDICLAIM
Originally introduced in 1984 Available to Indian residents Covers medical expenses for illness or accidental injury while

traveling abroad for business or holidays

Usually covers children above 6 months and adults up to 70

years
For above 70 years, extra premium may be charged In case of death outside India, expenses for transport of body,

cremation of body at foreign soil is reimbursable

No claim in case of child birth, abortion, miscarriage etc,