Common Health Insurance Terms
Proposal - “Proposal” is one of the most important documents when a person buys an insurance policy. This document contains all the relevant information about the person who is looking to buy an insurance policy from the company. It may include age, sex, occupation, the person’s medical history, etc.
Policy - Policy or Mediclaim policy means the terms and conditions applicable to the insurance plan so chosen by the person. The policy will contain all the details of terms, inclusions in the policy, the term plan and other relevant details to the insurance policy.
Basic Sum Insured - Basic sum insured in common terms, is the amount of money/coverage the insured person will get under the chosen policy without adding any discounts or bonuses.
Sum insured - The sum insured for a Mediclaim policy for senior citizens or individuals is the maximum sum standing at the end of one year that your insurance company will pay in case you are hospitalized. However, the company will not pay anything above the sum insured.
Extended Sum Insured - The extended sum insured for a health insurance policy means that it is an extension of the existing policy including bonuses and other extensions.
We/Our/Us - It means IFFCO-TOKIO GENERAL INSURANCE COMPANY LIMITED.
You/Your - It means the person who buys medical insurance.
Insured Person - The insured person here means the person under whose name the insurance policy has been bought.
Period of Insurance - Period of insurance is the time period of the insurance, meaning from the starting date of the insurance plan to the end date of the same insurance plan.
Hospitalization - This means being admitted into a recognized medical institution or nursing home or hospital for at least a minimum of 24 hours for any kind of treatment, for an ailment that you/insured person suffers from. Some insurance providers even offer you daycare services and cashless Mediclaim Policy allowing you to get your treatment without any cash.
Pre-Hospitalization Medical Expenses - This means that all the expenses that have been borne by the insured person before being admitted into a recognized hospital or medical institution; or borne by the insured person’s friends or family, whatever the case may be. This kind of expenditure will be reimbursed by the insurance company gave -
The treatment was given to the insured person by a registered practitioner;
The treatment for such ailment is according to the terms and conditions of the Mediclaim policy.
Post-Hospitalization Medical Expenses - These expenses cover all the expense that arises right after the medical treatment or hospitalization of the insured person. These expenses are of medical nature and are borne by the insured person after being discharged from the hospital. These expenses will be reimbursed by the insurance company, us, provided:
The medical treatment was given by a registered medical practitioner.
The hospital charges and the claim is as per the terms and conditions set for the Mediclaim policy, offered by us.
Medical Practitioner - A medical practitioner or a registered medical practitioner is a person or a doctor, who possesses a valid license, for practicing medicine and providing medical services to people, authorized by The Medical Council of India or by any other statutory authorities of the State Government or Central Government. All of the actions of the medical practitioner should fall under the jurisdiction and the scope defined and mentioned in the license of the medical practitioner.
Qualified Nurse - The qualified nurse can be a male or female, who possesses the valid registration from the Nursing Council of India or from any other statutory authority in any state in India.
Domiciliary Hospitalization - In simple terms “domiciliary Hospitalization” means that the insured person is given standard medical care for their illness, disease or injury in their house when the insured person is confined to their house for prevailing or existing reasons. However, the circumstances under which our company provides for medical care and takes care of the insured sum are the following:
The insured person cannot be transferred to a hospital due to their condition;
The insured person has to be treated at home due to the non-availability of hospital beds in the medical institution or
Pre-existing Condition - A pre-existing condition can be described as the medical condition of which the insured has been either been showing symptoms or has received treatment for in the past four years or 48 months prior to the medical insurance availed.
Day Care Treatment - Daycare treatment refers to medical attention (can be surgical) given to the insured person by a registered practitioner for less than 24 hours. The coverage of such procedures under our health insurance policy will depend on the following:
If the treatment is given under general or local anesthesia and did not require the insured person to be admitted in the medical institution, because of advanced medical facilities; then the daycare procedures should be listed under our medical plan to avail any kind of benefit.
*Note - Normal treatment or medical attention administered to the patient on an outpatient basis is not covered under our daycare procedures.
Provider Network –The term covers all the medical institutions, nursing homes, health care providers or hospitals that offer authorized medical care and treatment as enlisted by the Insurance Company and offer treatment to the insured person on a cashless basis.
Non- network hospitals - These hospitals are not enlisted by the company to offer the cashless medical facility to the insured person. In simple terms, it is any hospital that is not in the “Provider Network” of the company.
Emergency Assistance Service Provider - The emergency assistance service provider is any entity or body that offers medical support and care in case of emergency, to the insured person under their Mediclaim policy, when they are 150 km away from the insured person’s domicile address, provided that the entity or the body comes under Indian territories.
Medical Assistance Services - The medical assistance services are the emergency medical treatment or services offered by the emergency assistance service provider during situations of emergency, while the insured person’s registered domicile address is only 150 km away. However, the terms and conditions for the medical assistance service are similar to emergency assistance services.
Medical assistance services include - medical consultation, medically supervised repartition, medical evacuation and medical referrals.
Co-Payment - A part of the expense of the medical care and medical treatment is taken care of by the insured person themselves, while the remaining part of the medical treatment or care is offered by us. This term can be used interchangeably with “co-insurance.”
Emergency Care - Emergency care means the urgent and immediate medical care provided to the insured person in case of severe injury or ailment by a medical practitioner.
Grace Period - The grace period refers to a period of 30 days, offered by the company to the insured person of the Mediclaim plans, immediately after the due date of their premium payment. During this time, the insurance premium for your Mediclaim policy must be paid to ensure the safe running of your policies and plans. The failure to pay the insurance money during this time, i.e., during the grace period of 30 days, shall lead to the expiration or cancellation of your insurance policy with the company.
Inpatient Care - This can be described as the medical treatment that is given to the insured person in the hospital. However, this treatment lasts less than 24 hours. If such treatment comes under daycare procedures as mentioned by policies, then these medical services will fall under in-patient care.
Outpatient Treatment - This kind of treatment means that the insured person visits a particular department or a medical facility or a hospital or a nursing home in order to get some medical care regarding diagnosis or medical condition the insured person is already facing by a medical practitioner. Here the insured person is not admitted to the hospital, or treated under in-patient and daycare categories.
Day Care Centre - The daycare center is an institute, which has been set-up to offer day-care treatments to the insured person for ailments covered under the Mediclaim plans of the insured person. Proper departments that are set up under a recognized hospital also fall under this category. These day-care facilities must be registered under statutory authorities of India and must be run by or should be supervised by qualified medical practitioners. The day-care center must follow the following criteria:
The operations of the medical facility must be supervised by a registered medical practitioner;
The facility must have an adequately educated staff;
The medical facility must have and maintain daily records of the patients;
The medical facility must have all the surgical equipment for conducting surgeries at any given point in time;
The facility must share the maintained records with the authorities when demanded to do so.
Medical Expense - Medical expenses are the costs incurred for medical advice offered by the registered medical practitioner for a prevailing medical condition or the emergency medical care as availed by the insured person. However, it must be noted that these expenses should be true and fair and should not be inflated. These prices should match the actual prevailing prices in the market and should not be overcharged.
Cumulative Bonus - This term means the increase in the basic sum insured granted by us to the insured person without any associated increase in the permit for the insurance plan.
Dental Treatment - Dental treatment is any kind of treatment offered by a registered dental practitioner and may include various kinds of prescriptions, medications for pain management, crowns, implants, fillings or any other kind of cosmetic treatment. Unless specified explicitly by the insurance policy, dental treatment is covered by most Mediclaim plans.
Condition Precedent - This term means that the terms and condition of the policies under which the liability of our company is conditional.
Notification of Claim - It refers to the notification provided to our customer care or the TPA (Third-party administrator) regarding all the details and contact details.
Disclosure to information norm - This means that the insured person’s Mediclaim for the insurance policy becomes null and void due to misrepresentation of facts or due to the fraud or concealment of actual medical facts from the company. In such cases, the premium paid by the insured person is forfeited immediately.
Cashless services - These services are included in your Mediclaim plans and policies. Cashless service means that the payment of your medical treatment at a center will be paid directly by the insurance company. A capping or limit to cashless treatments is predetermined by the insurance company.
Contribution - This is defined as the right of the insurance company to call upon other insurers, who have also offered covers to the same person under different policies, to share the liability on an indemnity claim on the basis of pro-rata for the sum insured.
Renewal - This can be defined as the renewal or re-buying of the insurance policy or Mediclaim Policy by the insured person. The renewal happens with mutual consent. It must be noted that once the existing or the first insurance plan with our company has expired, your renewal process may be subject to a certain number of days of the grace period. Failing to renew your policy in the stipulated time would lead to the elimination of the renewal option for the particular Mediclaim plan.
Portability - This is defined as the right of an insured person to transfer their health plan to another insurer or any other insurance company. Through this option, the insured person gains the benefit of enjoying time-bound conditions and other pre-existing conditions, gained under the Mediclaim policy with our company.
Room rent - It is the amount of money charged by the hospital for occupancy of a room for 24 hours and may include other expenses for medical treatment provided by the hospital to the insured person.
Class “A” Cities - Class “A” cities include Mumbai, Kolkata, NCR Delhi, Jaipur, Pune, Lucknow, Ahmedabad, Kanpur, Chennai, Nagpur, and Bengaluru. This list is subject to revision from time to time at the discretion of the company.
Additional Benefits - This includes extra benefits offered to the insured person, above the limit of the basic insured sum after the payment for additional services, apart from the general cover offered by the Mediclaim plan.
Extension - This includes the optional coverage offered to the insured person after the payment of an additional fee other than the policy premium, for an additional benefit under the anon-going insurance plan.
Terrorism/Terrorist Incident - These are acts of violence committed with the explicit intention of causing harm and injury to life and property of any person. It includes acts of violence done specifically against a single individual or the entire nation. It also includes those incidents that can be verified by the government as acts of terrorism.
Alternative Treatment - These treatments cover an alternative method of treatment for ailments or injuries or pre-existing health conditions suffered by the insured person. In India, these alternative methods of treatment include treatments covered by Unani, Sidha, and Ayurveda, all of which are aimed at eliminating and treating the root cause of the ailment.