Critical Illness Health Insurance Terms You Need to Know

 It is important that you understand how the following terms are defined by IFFCO Tokio’s critical illness insurance policy before opting for it:

Injuries: It means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.

Diagnosis: It means diagnosis by a registered Medical Practitioner, supported by clinical, radiological, histological and laboratory evidence, acceptable to IFFCO Tokio.

Surgery: Also known as Surgical Procedure, it means manual and/or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or daycare center by a medical practitioner.

Medical Practitioner is a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council of Indian Medicine or for Homeopathy set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of license. The registered Medical Practitioner should not be the Insured or close family member.

A qualified Nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.

Pre-existing Diseases mean any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and/or were diagnosed, and/or received medical advice/ treatment within 48 months prior to the first policy issued by the insurer.

Any One Illness means continuous Period of illness and it includes relapse within 45 days from the date of the last consultation with the Hospital/Nursing Home where treatment may have been taken.

The contribution is essentially the right of an insurer to call upon other insurers, liable to the same insured, to share the cost of an indemnity claim on a rateable proportion of the Sum Insured.

Hospital means an institution established for in-patient care and daycare treatment of illness and/or injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of Section 56(1) of the said Act OR complies with all minimum criteria as under: --has qualified nursing staff under its employment round the clock; --has at least 10 in-patient beds in towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places; --has qualified medical practitioner(s) in charge round the clock; --has a fully equipped operation theatre of its own where surgical procedures are carried out; --maintains daily records of patients and makes these accessible to the insurance company‘s authorized personnel.

Intensive Care Unit is an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s),and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.

Inpatient Care refers to treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

Medical Advise: Any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.

Grace Period implies the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of Pre-existing diseases. Coverage is not available for the period for which no premium is received.

Notification of Claim is the process of notifying a claim to the Insurer or TPA by specifying the timelines as well as the address/telephone number to which it should be notified.

Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.

Third-Party Administrator means any person who is licensed under the IRDA (Third Party Administrators - Health Services) Regulations, 2001 by the Authority and is engaged, for a fee or remuneration by an insurance company, for the purposes of providing health services.

Network Provider means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility.

Non- Network means any hospital, daycare center or other providers that are not part of the network.

Portability means the transfer by an individual health insurance policyholder (including family cover) of the credit gained by the insured for pre-existing conditions and time-bound exclusions if he/she chooses to switch from one insurer to another.

Congenital Anomaly- Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position. a. Internal Congenital Anomaly: Anomaly which is not in the visible and accessible parts of the body. b. External Congenital Anomaly: Anomaly which is in the visible and accessible parts of the body 40. Reasonable and Customary Charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved.

Subrogation shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source.

Condition Precedent shall mean a policy term or condition upon which the insurer's liability as per critical illness cover is conditioned upon.

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