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Health Insurance Policies - Fine Prints

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Health insurance is one definite way towards achieving ‘health for all’ in the world. Most governments including the US government are striving towards this goal. UK already has the National Health Service and so have most European countries. But it is the lesser developed countries that need to get health insurance high on the government’s priorities and demand a higher chunk of the GDP.

Health Insurance Policies

In India, health insurance is gathering momentum, with many state governments tying up with private insurance companies to provide decent health cover for their people. Healthcare in India is seeing a gradual shift of focus from public sector hospitals to private corporate hospitals. However, by and large the common man is still ignorant about the very concepts of Insurance. Health Insurance is only a component of different types of insurance cover.During the last elections - ‘Health insurance for people’ became a new mantra for capturing vote-banks in some states of India. It is very well for the government to give pledges to the people to win votes, but the challenge to deliver decent health-care to their subjects in the comfort of the corporate hospitals is likely to be daunting. The premium paid is sometimes very meager and can provide for very little.

Understanding the fine print of the insurance will help you understand the scope of the policy and its limitations, which are seldom spelled out by the agent selling you their products. This article has been created specially for the layman, to explain, discuss and interpret only the important clauses incorporated under Health Insurance Policy by various PSUs (Public Sector Undertakings) and Private Insurance Companies in India.

Before discussing and interpreting the important clauses as stated in the policy cover, it is important to note that there are no standard inclusions or exclusions, and the numbers and wordings of the clauses varies from organization to organization (both – PSUs and private insurance companies), however the contents i.e. Terms and Conditions remain more or less uniform based on the guidelines issued by IRDA (Insurance Regulatory and Development Authority) - a regulatory body for the Insurance sector in India which is a subject under Central Government of India.

Broadly the Insurance sector is divided into Life insurance and General Insurance sector as depicted in the following table -

Classification of Indian Insurance Sector
Health Insurance-Classification
As depicted in the classification chart, health insurance is one of the constituents of Non-Life/General Insurance sector in India.

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ila_upadhya Sunday, August 17, 2014
Hi, My father [Age-62yr] underwent Cardiac by-pass surgery in 2006 and after that he undergoes annual cardiac check-up every year. He is in good health now. I want to take a Mediclaim policy for him which covers him for any possible future hospitalization (for all generally covered diseases including his pre-existing condition). Please recommend me good options which is also not very expensive.
rajmiba2001 Saturday, February 8, 2014
Hi, I reside in a Metro city and my child is admitted in a Child Care Centre / Nursing Home last night due to illness last night. However the Nursing Home is a small one and has 5-6 beds only. But it is registered one under the regulatory authorities. I seek clarification on below: "HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner. OR In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home andshould comply with minimum criteria as under: [1] It should have at least 15 in-patient medical beds in case of Metro cities, A Class cities......................." Will I be able to claim for reimbursement? Regards, Sameer
sameerbh Tuesday, May 7, 2013
My Wife was Pregnant and was in 9th month. All was normal but one night we finish our dinner and went to our bed. But suddenly at midnight my wife found Heavy Bleeding. We immediately run for our Doctor treating her. She refer us to one of the Big n Best Hospital of our city. The problem raised is called Ante partrue Hemarhage [APH] according to Doctor. As due to heavy bleeding my wife was almost in shock. And to save the life of both (Baby n Mother) a Emergency LSCS was done. A baby born via Cesarean. So, I submit a file for claim against my Medical Policy with United India Insurance Co. but that was rejected by saying "Treatment arising from or traceable to Pregnancy (including Caesarean) not covored. But as per me, as My Wife have no Labour Pain nor the whole process was done because of or for Delivery. So, kindly guide me for the same. Should I go to Insurance Ombudsman???
VinodLudhiana Saturday, April 13, 2013
I am 26 years old and I would like to undergo Lasik Operation. My sight is -7 in both eyes. Can I get free operation in Hospitals?
bchandra Monday, February 11, 2013
my mediclaim in cashless rejected due to reason stating that the policy not completed 2 years period, but my previous policies existing last 4 years without any break but it is in different companies like first three years in A [i.e 2009-11]and one year in B(i.e 2011-12), now in C (i.e 2012-13)company. at the time of last renewal (i.e 2012-13)the insurance company recorded only previous year without referring the existing all previous policies under portability,they have not refer anywhere all the previous policies, now can it be be treated as contineuous policy in portability clause.can we have an option to add the previous policies for an updation purpose.
kpreddy Wednesday, February 6, 2013
S dr Anand yr eye hospital is eligible and u may contact TPA for cashless facility too
Srint Thursday, December 13, 2012
Myself is Eye surgeon.I am having good clinic and adjoining fully equipped eye OT in a commercial complex which is registered from District Chief Medical Office. As eye surgeries are day care surgeries , the clinic has only 2 beds. Is this center fulfills criteria for cashless TPA health insurance companies.
anand74 Thursday, August 16, 2012
Post your comments Hello, I am 24 years old and I would like to undergo Lasik Operation. My sight is -5 in both eyes. I have ESIC Card. Can I get free operation in Hospitals like Sankar Foundation or LV Prasad Eye institute?
kp8688 Tuesday, April 24, 2012
Hi my age is 31 years and I do not have any mediclaim policy upto now.Few months ago I was diagonsed with TYPE 2 diabeties.I want to take a family floater mediclaim policy for me and my wife but I am not very sure if I am eligible to take a Mediclaim policy or not and is Diabeties covered under pre existenc disease.Recently I applied for an ICICI mediclaim policy but they rejected my policy giving explanation of Diabeties on treatment. I will appreciate some body's help on this. Vijay
vijayvani Friday, January 6, 2012
You can go for Star Health policy
Akash.T Thursday, July 12, 2012
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