‘Make things Easier for the People You Love’ After life insurance, health insurance is perhaps the most imperative plan one should have in his/her portfolio. It works in a simple manner, the insured pays regular premiums to the insurer in return of which the insurer promises to cover him financially in case of a medical contingency.Health insurance is not only about reimbursing an individual for the expenses on his/her medical treatment. A Health Plan also assists in being a tax saving tool. The insured gets a substantial tax exemption under section 80D.

These two terms are too often used interchangeably. However, there are some sharp differences between them. Mediclaim is limited to bearing hospitalization expenses only but health insurance covers a wider aspect and covers areas which go beyond just hospitalization.

A basic Mediclaim policy reimburses the expenses of treatments which requires the patient to be hospitalized for a day or more. For such a disease or accident, it covers all expenses even before and after the actual hospitalization period.

You get reimbursements of hospital bills to the sum insured whereas a top-up plan would cover costs after a certain limit has been reached. “A top-up health policy is an additional coverage for people who have an existing individual plan or a mediclaim from the employer.”

Most insurance companies use one of two definitions to identify such conditions. The “objective standard” definition states that a pre-existing condition is one in which the patient has received advice from a medical person or has been treated before he/she was enrolled in a new medical insurance plan.

If the insurance policy that you have chosen has the co-pay clause then you have to pay a part of the expense by your own and the insurance company will take care of the rest. Various insurance companies provide co-pay clauses in their plans.(like United India Insurance Company, New India Insurance Company, SBI Insurance etc.). The amount to be co-paid is mostly a fixed amount for various services provided and medicines needed which vary depending on the kind of treatment and medicines whichare required. For instance, if the insurance policy selected by you carries a co-pay clause of 10% and the medical expenditure went up to Rs. 50,000 then you need to pay Rs. 5000 by your own and the insurance company will bear the remaining Rs. 45,000.

Cashless policies mean that the health insurance company settles the bill directly with healthcare provider, whether a hospital or a nursing home. This is to reduce the direct financial burden on insured individual at the time of hospitalization.

The sum paid to the health insurance company by an insured person for a fixed time period is the Mediclaim Premium. The loss borne by the policyholder due to illness is in turn covered by the company. During policy renewal, premium has to be paid.

The definition of pre existing diseases states that any condition/s which had signs or symptoms or were diagnosed and had received medical advice/treatment in a period of 48 months before taking the first policy. Health insurance companies are no longer allowed to charge more or deny coverage to any individual due to pre-existing diseases like asthma, diabetes or cancer. They are also not allowed to limit the benefits provided for the conditions. Once you have taken the insurance they are bound to cover the treatment of any pre-existing disease.

TPA or Third Party Administrator refers to a company/organisation/agency which holds a license from the Insurance Regulatory Development Authority (IRDA). They can process claims, both corporate and retail policies along with providing facilities of going cashless by being an outsourcing entity of an insurance company.

TPAs are the intermediaries who are parts of the medical billing system operating as a network or as access networks to price claims. The labour unions which provide coverage for its members most often use the TPA pricing.

A third-party administrator (TPA) is an organization that processes insurance claims or certain aspects of employee benefit plans for a separate entity. … While some third-party administrators may operate as units of insurance companies, they are often independent.

Incurred Claims Ratios are published by the IRDA or the Insurance Regulatory Development Authority in India. It refers to the overall ratio of the dividend paid by the company to the total amount of premium collected during the same time period.

When a woman is pregnant with a child, there are risks involved in that too. The insurance companies see their condition to be riskier and consider the expenses to be more when they get applications from customers for the coverage. Prior to the Affordable Care Act, pregnancy was considered to be a pre-existing condition and the insurers often denied coverage. Now they aren’t allowed to do that.

  • Adult dental services. Dental services are frequently left out of health plan benefits, with 81 percent excluding it.
  • Children’s eye glasses. 87 percent of health plans do not cover children’s eye glasses.
  • Weight loss surgery.
  • Children’s dental check-up.
  • Protect the interest of a Minor Child or a Special Child.
  • Acupuncture.
  • Infertility treatment.
  • Cosmetic surgery.
  • Long-term care.

Medical Insurance and Plastic Surgery. In general, each specific insurance company determines what procedures they will or will not cover. The biggest factor insurance companies consider is whether the procedure is reconstructive or cosmetic in nature.

It’s not covered by medical insurance as it’s considered to be a cosmetic procedure. Unless there are some therapeutic benefits attached to it not be covered by the company. At times, health insurance covers liposuction for treating subcutaneous lipomas (which are small fatty tumors beneath the skin.)

Cosmetic surgeries are usually not covered by insurance so you need to bear the expenses on this one on your own. Occasionally, they do pay for a procedure called Panniculectomy. It only removes the excess skin and fat.

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