A health insurance policy is a contract between an insurance company and an individual or his sponsor (e.g. an employer).
The contract can be renewable annually or monthly.
Insurance Regulatory Development Body (IRDA)
A regulatory body, controlled by the Indian Government, governing insurance companies across India.
The headquarters of IRDA are located at Hyderabad.
Mission of IRDA
The main mission of IRDA is:
► To protect the interests of the policyholders,
► To regulate, promote and ensure orderly growth of the insurance industry
Health Insurance Companies in India
Health insurance is a sub-categorization of General (Non-Life) Insurance in India. There are:
► 4 PSU/Government Insurance Companies
► 14 Private Insurance Companies
► 3 Stand-Alone Private Health Insurance Companies
Third Party Administrator (TPA)
A TPA is a specialized health service provider, introduced by the IRDA, rendering the following broad-spectrum services:
► Networking with hospitals
► Facilitating hospitalization processes
► Claim processing and settlement
Types of Insurance Policies
Individual Policy Protection is provided to the policyholder against the expenses incurred due to disease or injury.
Group Policy/Floater Policy Covers entire family under one policy with one sum insured and one premium.
Types of Insurance Services
Cashless Hospitalization/Network Claims is a facility provided by the insurers wherein the insured can get admitted and undergo the required treatment without paying directly for the medical bills.
The medical expenses incurred shall be settled by the insurer.
Types of Insurance Services
Non-Cashless Hospitalization/Non-Network (or Reimbursement) Claims is a facility where the policyholder pays the medical expenses incurred at the hospital. After being discharged, a reimbursement can be claimed.
Purchasing Health Policies
► Decide on number of policyholder(s)
► Decide on Sum Insured for each individual
► Choose between individual/floater policies based on specific requirements
► Compare & analyze products/services of various companies
► Verify the quality of healthcare services
► Contact an agent to help with purchase
► Remember that an insurance policy is a contract and must be executed in good faith.
► Disclose medical history with relevant records for proof.
► Read all the exclusion clauses carefully before treatment.
► Read product pamphlet thoroughly and understand the claim filing process.
► Approach Grievance Redressal Cell of IRDA to register complaints.
► Annual renewal of the policy.
► Payment of premiums before the expiry date.
► Review the Sum Insured amount periodically.
► Maintain all medical records/documents in one file.
► Build awareness of network hospitals included under the plan.
Documents Check-List for filing Claims
► Original Claim Form with seal and signature from the treating physician.
► Original Discharge Summary
► Original Hospital Bill
► Original medical receipts
► Original Lab Reports
► Address Proof
► Age Proof
How to file Claims
► Arrange medical documents in an order before submission.
► Submit the original documents to the TPA. Claimant should retain a set of copies.
► Submit claim within 30 days of discharge from hospital.
Ombudsman is a special court constituted under IRDA for addressing grievances associated with Insurance claims.
The claimant can approach the Ombudsman for resolving claim issues.
Importance of Health Insurance
► Health insurance is an expense, but its importance helps to defray that expense.
► In unexpected health events, insurance helps to minimize uncertainties, counter risks, mitigate financial stress and provide security to human life.
► It is a safe investment option with broad-spectrum benefits for policyholder.
Disclaimer - All information and content on this site are for information and educational purposes only. The information should not be used for either diagnosis or treatment or both for any health related problem or disease. Always seek the advice of a qualified physician for medical diagnosis and treatment. Full Disclaimer