Frequently Asked Questions benefits and coverages Questions and Answers Related To benefits and coverages

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Health Insurance Claim Assistance

1 Will my health insurance cover for doctor visits ?

There are some plans which provide OPD as an optional cover.

2 What are limits or sub limits in my health insurance ?

Your insurance policy may have capping or maximum limits for specific diseases, treatments or for room rents. Theses are called limits or sublimits in the policy

3 What is Domiciliary Hospitalization in health insurance?

Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances: - the condition of the patient is such that he/she is not in a condition to be removed to a hospital, or the patient takes treatment at home on account of non-availability of room in a hospital.

4 Which insurance company sells Arogya Sanjeevani policy?

IRDA has asked all Insurers to provide Arogya Sanjeevani policy -- a standard health insurance policy, which provide a basic health cover between Rs 1 lakh and Rs 5 lakh.

5 What is pre Hospitalization and post hospitalization expense

Pre-hospitalisation expenses are medical costs incurred by the insured before getting admitted in a hospital. Post-hospitalisation expenses are medical costs incurred after discharge from the hospital. These are covered by most health insurers. Need to note that the medical expense has to be for the same condition for which hospitalization was required, and hospitalization expenses has been approved

6 Does health insurance pay for tummy tucks?

No, As per current guidelines, tummy tucks is not covered. There may be some changes in guidelines after October 2020

7 What are some Add on covers available

There are various add on covers that you can add. Some popular ones are Hopsital Cash, Criticall Illness, Room Upgrade or waiver of room rent capping. Some Insurers offer Personal Accident cover as an add on too. Kindly note some of these covers may be inbuilt in your base cover, and some of them you may have the option to buy -- will depend on the plan and Insurer you choose.

8 Can i get the benefit of Maternity immediately after marriage

All insurers have a waiting period on Maternity cover, from 9 months to 4 years

9 Is there a capping on ICU charges ?

Some Insurers may cap or put a maximum limit on the cost of ICU charges per day you can take in the plan. This is the ICU rental just like a Room rent and excludes treatment, cost of medicine etc. Capping if any will be defined as a % of Sum Insured or a fixed value capping.

10 Is Ayurvedic treatment covered by health insurance?

Yes, Ayurvedic treatment is covered as a part of AYUSH treatment. AYUSH stands for Ayurvedic, Unani, Siddha, Homeopathy.

11 What do you mean Hospital Cash Benefit or Daily Cash benefit ?

The daily hospital cash benefit is a plan that pays a fixed amount for each day that you are hospitalized. The amount paid is fixed at the time of taking the policy. This benefit cover can be taken as a rider or also as a standalone cover available from few Insurers.

12 What does a No Limit room rent or Actuals mean?

A "No-Limit" or " Actuals" room rent eligibility has no capping on the amount to be spent per day for your room rent. Please do check some insurers have a No limit but excludes suites in 'Category of rooms'

13 Does Health Insurance cover air ambulance?

Many Insurers offer air ambulance covers. This would cover expenses of an air ambulance when the recommended treatment is not available in your city of temporary stay.

14 Is maternity expense covered in Health Insurance

Maternity coverage is available with health insurance as an optional cover.

15 Shall I buy a plan with a co-pay

Insurance plans with co-pay may have lower premiums. Many senior citizen plans are only available with co-pay.

16 Are surgeries covered by health insurance?

Yes, surgery required as a part of treatment is covered. Surgeries like cosmetic surgery, bariatric surgery etc. are not covered in normal Healt Insurance policies

17 Is Naturopathy treatment covered?

Yes, Naturopathy is covered as a part of AYUSH treatment, AYUSH stands for Ayurvedic, Unani, Siddha, Homeopathy.

18 What category of rooms are covered ?

Insurers may specify 'Single Private Room' which means - there is no capping on the rent but room has to be single private, Deluxe rooms may not be paid. Some Insurers cover 'All category of rooms, excluding suites' while some insurers cover 'All categories including suites'. Some others may cap it as a % of Sum insured. Please check before buying

19 Are day procedures covered in health insurance policies ?

Day Care treatment is which starts and ends on the same day. Usually insurers will have a specific list of 200-600 or more procedures that they cover.

20 Will health insurance pay for travel

Yes some companies pay next of kin to join insured patient, if the hospitalisation takes place outside the usual city of residence of the patient. Please acheck if the cover is available in your policy or not

21 Are infertility treatments covered

Most health insurance products do not cover cost of intertility treatment, currently

22 What is deductible in health insurance?

It it the amount that you will have to pay yourself, before the insurer pays the balance amount claimed. To be more precise - Deductible means a cost sharing arrangement in which the insurer will pay any benefits to the insured only after the insured has paid a specified rupee amount.

23 Are lab tests and cost of medicines covered in Health insurance ?

Different products have varying coverages, including pre and post hospitalisation expenses.

24 Does health insurance cover therapy?

Yes. If advised by consulting Doctor limited to post operative recovery periods OR as defined in your policy.

25 Are cosmetic procedures covered under health policy?

Elective cosmetic surgery is usually not covered under most health insurance plans because it is optional and not considered as a medical necessity. In case of accidents reconstructive surery may be covered if that is a medical necessity

26 Are accidents covered in the health insurance

Hospitalisation due to accidents is covered and claim is paid as per the applicable coverages.

27 What is Arogya Sanjeevani health insurance policy?

It is standard health insurance policy, which provide a basic health cover between Rs 1 lakh and Rs 5 lakh. Launched in April 2020, all companies need to offer this policy, called Arogya Sanjeevani Policy followed by the name of the respective insurance company.

28 is Hospitalization for investigation purpose covered?

It is not covered unless diagnosed for a covered illness.

29 Is there health insurance for mental health

Mental health is covered under health insurance as per Mental Health Care Act 2017

30 Can you backdate health insurance?

No, you cannot backdate any health insurance policy.

31 Can I book a suite room or a deluxe room during hospitalization

It will depend on the type of plan and room rent cover that you opt for. A "No-Limit" or " Actuals" room rent eligibility will cover a suite or deluxe room. Insurer may also call it 'All categories of rooms' - INCLUDING suites Please check the room rent capping, if any, in your plan.

32 What is the meaning of AYUSH treatment?

Ayush expands to Ayurveda, Yoga, Unani, Sidha and Homeopathy. Ayush treatments are forms of alternative treatments other than “Allopathy” or “modern medicine". Most insurers provide coverage for Ayush treatmen

33 What are Ambulance charges in health insurance ?

In case you hold a health insurance policy and get hospitalised the plan will cover limited costs incurred on using an ambulance to transport you from your home to the hospital, hospital to hospital or vice-versa. Most policies include ambulance charges upto a specified limit.

34 What is the meaning of co-pay ?

Co-pay is a prefixed percentage or a small portion of the claim amount you can choose to pay for from your pocket, and the remaining is paid for by your Insurer

35 Are organ transplants covered?

Yes it is covered. Some insurers additionally cover donor expenses , harvesting & other expenses.

36 Do I get a claim if hospitalisation is less than 24 hours?

There must be hospitalization for more than 24 hr for a claim except for domiciliary hospitalisation or for day care treatment & other specified treatments which takes less than 24 hours. These will be specifically mentioned in your policy.

37 What do you mean by Restoration or Reinstatement benefit ?

Many insurers restore your full or part of your sum insured, in the policy year post a claim. Some Insurers will do it multiple times in the year and also for same disease, while some insurers will only restore it once in a policy year and may not restore for same disease

38 What all expenses are covered under maternity expenses?

Maternity expense / treatment shall include the following Medical treatment Expenses: i. Medical Expenses for a delivery (including complicated deliveries and caesarean sections) incurred during Hospitalization; ii. The lawful medical termination of pregnancy during the Policy Period limited to 2 deliveries or terminations or either during the lifetime of the Insured Person; iii. Prenatal and postnatal Medical Expenses for delivery or termination.

39 Are there any disease-specific limits?

Yes, there may be specified limits for treatment in cases like cataract,maternity etc