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A Health Insurance policy stipulates that a Claim is valid only if the Insured has been hospitalized for at least 24 hours.
However, there are certain surgeries that don't require 24 hours of hospitalization, thanks to advances in science and technology.
This is where a compulsory 24 hours hospitalization clause needed relaxation to include such expenses.
Because this was causing moral hazard as insured and the hospital with mutual understanding extended hospitalization to 24 hours to get coverage. Either in real time or just in papers.
Insurers have listed around many such treatments called “Day care procedures where and allow the medical coverage even if 24 hours minimum hospitalization is not given. Sample list is given here.
Even if it is not listed in the policy document, you can request them to include it and take approval before going for admission.
Don’t get confused between day care procedures and outpatient expenses.
No insurance company pays for the stand alone Outpatient treatments like POP because of bone fracture, stitches with local anesthesia, doctor consultations, health tests etc.,
There are more than 580 Day Care procedures. The number of such Day Care procedures being covered differs from insurer to insurer.
Only 24 hours inpatient hospital admission is not enough. There should be an inline treatment as well.
Let's say I experience chest pain at night and I go to emergency hospitalization thinking it may be a heart attack.
After being admitted and undergoing tests, the doctor determined that my chest pain was due to a gastric problem and that no treatment was required.
I will be happy that nothing has happened to me, but I will be disappointed that my claim for admission and health tests have been rejected because there is no inline treatment.
But in case the doctor finds some issue with my health and gives me some treatment with minimum 24 hours inpatient hospitalisation, then the hospitalization bill along with those health tests and medicines gets covered.
In certain cases when the patient’s condition is not such that he can be moved to Hospital, insurers agree to consider the claim and reimburse the expenses under the Domiciliary hospitalization cover. However you need to check if your policy has such cover.
Reasonable and customary charges is one of the most dreadful clauses in Health Insurance.
The terms reasonable, usual and customary refer to the average claim paid by your Insurance Company for a particular ailment.
A charge is considered reasonable, usual and customary if it matches the general prevailing cost of that service within your geographic area, which is calculated by your insurance company.
The insurance company then uses this information to determine how much it’s willing to pay for a given service in your area.
This means that if your hospital charges above the reasonable and customary charge, you may have to pay the remainder.
This clause gives a lot of room for an insurance company to cut down the claim amount and in fact it is the most disputable clause in the whole policy document.
Apart from room rent all the other items as listed above under hospitalization expenses are dependent on how the room rent is being charged at the hospital.
This feature has a great impact on the overall claim amount payable under health insurance.
Insurance companies put a sub-limit (Capping) on the room rent payable under a health insurance policy in case of hospitalization.
If you opt for a room rent crossing the limit mentioned in the policy, along with excess rent, the insurance company will deduct the cost of other services like doctor’s fees, surgery charges, etc. Proportionate to the room rent charges.
This is because, in any hospital, the cost of exactly the same set of services is charged differently for different room types. The hospitals charge low cost for rooms with lower rent and high cost for rooms with higher rent.
Charges which are based on MRP (like medicines) are charged the same for all types of rooms. Hence, these charges will have no impact on room rent capping.
Let’s understand this better with an example:
| Factors | Actual Room Rent | Claim Amount after Deduction |
| Room Rent | 4000 | 2000 |
| Surgery | 10000 | 5000 |
| Doctors fees | 400 | 200 |
| Medicines | 460 | 460 |
| Total | 14860 | 7660 |
Hence, it’s always advisable to select your health insurance policy wisely by verifying room rent you are eligible to opt for. It is good to have no cap on room rent to feel free to select the room as per availability and rent charges in the hospital.
Some insurers also offer additional “per day cash” if you opt
We can call this clause "Fine print of Fine prints”
Once you have paid premiums for eight consecutive years, your insurer is required to pay all claims as per the policy limits as of April 1, 2021.
The Insurance Regulatory and Development Authority of India (IRDAI) states in its guidelines on standardisation of terms and clauses in health insurance that no health insurance claim should be challenged after an eight-year moratorium period has expired. An exception to this rule is fraud that has been proven beyond a reasonable doubt and permanent exclusions outlined in the contract.
Thus, policyholders do not need to wait in anticipation for health insurance companies to approve claims after eight years. The claim will have to be settled within the limits of the medical insurance policy.
Once the policy is accepted by the insurance company, the policy must be renewed regardless of the health condition of the insured, regardless of claims, regardless of age, and regardless of medical inflation.
That means you do not worry about the coverage in old age as long as you pay the premium on time and renew the policy on time.
At the most the insurer may stop sending you reminders about the policy renewal if they don't want to renew. Keep a reminder in your mobile app that will be triggered every year one month before my renewal date.
The "Free look" period applies to all types of health insurance. The period of time varies between 15 and 30 days, depending on the insurance company. It begins on the day you receive the policy documents. In the event that you feel the purchased policy does not meet your requirements, or if you would like to switch to a different health plan from the current one, you are able to cancel it within the specified period. A minimal cancellation fee will apply, and the remainder of the amount will be refunded to your account after the cancellation process is completed.
There are some key takeaways of this clause in health insurance. Let’s check them out in detail:
Time Limit:
In the free-look period, a cancellation must be made within 15 to 30 days of receiving the policy documents. The period of time that your insurer allows during this period will be outlined in your insurance policy. In order to initiate the cancellation process, you need to prove the starting date of the insurance policy, i.e., the date you received the documents.
Credentials and Details:
In order to initiate the cancellation process during this period, you will need to provide certain details that the company will require. You can usually find the list of required details on the company's official website. For this process, you will need to provide proof of start date (date when you received the documents), information about the insurance agent (if involved), and a reason for cancellation, among other details. Your bank details are also required for the refund process.
Documents:
To initiate the cancellation process, some documents are required. These include original documents, receipt of first premium payment, cancelled cheque, etc. An indemnity bond is required in the absence of the original documents. Your insurer may require other documents as well. The list of required documents can be found on the company's official website or by contacting customer service.
Partial Refund:
The cancellation refund even during the free-look period is not 100%. The insurer will most likely cut a minimal fee for charges incurred on stamp duty, medical test, the proportionate risk premium for the coverage period, etc.
Whether you buy health insurance online or from an agent, always make sure you read all the scheme related documents carefully and make an informed decision. If after that you feel the need to change your decision, go ahead and avail the benefits of the free-look period and cancel your insurance anytime within the duration!
The grace period is the extra time you'll have if you miss your policy renewal premium deadline. The failure to pay within the grace period could result in the cancellation of your medical insurance policy or penalties.
A grace period gives you a reasonable opportunity to pay your health insurance premium if, for some reason, you cannot make the payment. The majority of insurance companies offer a grace period of 15 days for paying medical insurance renewal premiums. However, there are companies that offer a 30-day grace period.
Grace periods can vary depending on the insurance company and the type of mediclaim policy you purchase. Furthermore, it is not necessary for every insurance company to provide the benefit of a grace period.
Grace periods may differ between insurers, for instance. Or they may be the same. Therefore, you would need to check with your insurance company or read your policy wordings to see if a grace period is offered and for how long.
However , there are disadvantages of not renewing your health policy
on time.
Below are some of the drawbacks of not renewing your health policy on
time:
No Coverage available in the grace period : Insurance companies offer insurance protection in exchange for the premium protection. In case you haven't paid your insurance premium on time, your insurer will not provide you with coverage. Consequently, you will not be able to receive coverage benefits during the grace period.