While health insurance terms generally carry similar meanings across most plans, it's important to note that there might be some variations in your specific plan. Although the actual definitions will provide clarity, practical examples will demonstrate the practical applications of these terms in real-life scenarios.
Here is a compilation of essential health insurance terminologies that are commonly misunderstood but crucial to know:
1. Sub-limit
The sub-limit is a plan-specific health insurance term that refers to the pre-determined cap on the parts of your insurance claim to be applied on hospital room rent, treatment of a certain medical condition or post-hospitalisation costs etc. Let's understand this with an example:
Susheela purchased a health insurance plan that offers a sum insured of ₹20 lakhs. The policy comes with a 25% sub-limit for cataracts, out of the total sum insured, i.e., ₹5 lakhs. Hence, Susheela cannot claim more than ₹5 lakhs for the treatment of cataracts.
The types of sub-limits that are most commonly present in health insurance plans are room rent, ICU rent, specific ailment limit, etc.
2. Co-payment
One of the most heard health insurance terminologies is co-payment. It simply refers to sharing the burden of medical expenses between the insured and the insurer. At the time of purchasing a health insurance policy, the co-payment is decided. It can either be a fixed percentage or a fixed sum. Thus, the co-payment is part of the total claim amount that is to be paid by the policyholder/insured. Here's an example:
Sunder has a health insurance policy worth ₹10 lakhs. The co-payment is fixed at 10% irrespective of the total claim amount. Recently, Sunder met with an accident and raised a claim of ₹1 lakh. So, 10% of 1 lakh, i.e., ₹10,000, had to be paid by Sunder, and the health insurance provider paid the remaining amount.
3. Deductibles
Deductibles are the amount/percentage of health insurance claim amount that the insured has to bear. Now, health care terminologies like deductibles and co-pay may be confused at times. Although both terms refer to the amount paid by the insured, deductibles are primarily a limit over which only the insurer pays the bill. Here is an example:
Santosh Nair has a health insurance plan of ₹2 lakhs with deductibles of ₹10,000. In this case, Santosh can only raise a claim when his medical bills cross ₹10,000. Usually, top-up and super top-up plans have a deductible feature, wherein a claim is admissible only after the claim amount crosses the threshold limit of the deductible.
4. Pre-existing Disease (PED)
The health insurance term PED stands for Pre-Existing Diseases or Ailments.
Plans like Care Freedom from Care Health Insurance offer coverage for PEDs like diabetes and high BP. The policy comes with a sum insured option of up to ₹10 lakhs. Also, unlike the other health insurance plans, the policy comes with a lower waiting period of 24 months.
5. Automatic Restoration
In automatic restoration benefit, the basic sum insured of your plan is automatically restored once it gets completely exhausted during the policy period. To avail of automatic restoration benefit, renewal is the best time Here is an example for better understanding:
Reena Kundra opts for Care Supreme Plan from Care Health Insurance with a sum insured of ₹10 lakhs. The plan comes with the benefit of automatic restoration. For her gall bladder surgery, Reena’s hospital bill came to around ₹10 lakhs, which exhausted her entire sum insured. A few months later, she had to avail of kidney-related medical treatment of ₹6 lakhs. Thankfully, her policy sum insured was automatically restored with the restoration feature, and thus, the ₹6 lakhs for her treatment was covered under the Care Supreme Plan.
6. No Claim Bonus
Maintaining good health can be rewarding in many ways. For example, when you stay fit and do not raise a claim throughout the policy year, your insurer may give you a bonus, called the No Claim Bonus. The bonus gets added to your sum insured and thus aids the basic coverage.
With Care Health Insurance, a claim-free year may make you eligible for a 10% increase in the sum insured for the upcoming policy year. The NCB can go up to 50% of the sum insured.
7. Cashless Benefit
One of the most popular health insurance terms is cashless benefits. As the name suggests, in a cashless claim, the insured/policyholder does not have to pay the hefty medical bills from his/ her pocket. The insurance company directly settles the bills with the hospital. Only the deductibles/ co-pay and inadmissible costs have to be paid by the insured.
In order to avail of a cashless benefit, one has to receive medical services from one of the network hospitals. A cashless benefit allows individuals to avail the best medical care well within their vicinity. The best health insurance in India is most likely to offer cashless claim benefits in a large network of hospitals, for example, with Care Health Insurance plans, you can avail of cashless treatment at over 21,500+ hospitals across the country.
8. Pre-Authorisation
Claim settlement is often a layered procedure. In a cashless claim, a pre-authorisation formality has to be fulfilled in both planned and emergency hospitalisation. Pre-authorisation can also be called provisional authorisation where your insurance company will communicate to the hospital whether the raised claim will be admissible or rejected. The claim process is started by filling out the pre-authorisation form.
The form is to be filled 3-5 days before admission in case of planned hospitalisation and within 24 hours in case of an emergency admission. After the initial approval, the final approval will be given by the insurer after verification of the documents.
Note: Pre-authorisation of the claim does not imply acceptance or rejection by the insurance company. Once the treatment begins, the diagnosis or the course of action may vary, thus having a bearing on the approval.
9. Waiting Period
Health insurance terms like waiting period are essential to understand. As the name suggests, the waiting period refers to the tenure during which you cannot raise a claim. Usually, the waiting period starts from the day of policy inception. In most plans, a claim for an illness cannot be made within the first 30 days of policy purchase. However, hospitalisation needed because of accidental injuries is covered from day 1.
The waiting period may vary from illness to illness as well. In the case of pre-existing illnesses, it can range from 2 to 4 years.
>>Also Read: Things You Should not Miss about Waiting Period
10. Portability
After purchasing a health insurance policy, at some point, you may find it to be insufficient, or you may need more than completely satisfied with your insurance provider. Be it the premium charged, the sum insured, or the benefits offered, you may not find your purchased plan enough to cover your medical needs.
In such a case, you can definitely port your existing health plan to one of the plans offered by Care Health Insurance. The process of porting needs to be initiated about 45 days before the last date for health insurance renewal. The no-claim bonus, credits and the sum insured remain intact even after you port your health insurance plan.
11. Domiciliary Hospitalisation
Your insurer will also pay for the “care at home” if prescribed by the doctor. Domiciliary hospitalisation is advised by a medical practitioner when either there is unavailability of rooms in the hospital or the insured is too unwell to be moved to the hospital. Here, depending on the plan that you have opted for, the expenses may be covered up to a specified sub-limit and for a specified number of days.
Conclusion Lines
In case there are other terms and sections of your health insurance plan that you find difficult to comprehend, do not hesitate to reach out to your insurance provider. Make sure to clear all your doubts and concerns before you finalise a plan that you prefer. Know the details and opt for the best suited plan at your earliest!
Disclaimer: Plan features, benefits, coverage, and claims underwriting are subject to policy terms and conditions. Kindly refer to the brochure, sales prospectus, and policy documents carefully.
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