This section details all medical expenses your insurer will cover when you require treatment.

Hospitalization Expenses

If you're admitted to a hospital for more than 24 hours, your policy will cover:

• Room rent & boarding - The cost of staying in a hospital room, with some policies allowing "at actuals" (no limit) while others have a cap.
• ICU charges – If you need intensive care, the costs are covered (some plans may have a limit).
• Doctor’s fees – Consultations, surgeon’s charges, anesthetists, and specialists’ fees are included.
• Diagnostic tests –X-rays, MRIs, blood tests, and other necessary medical investigations.
• Medications & consumables – Medicines, injections, IV fluids, blood transfusions, etc.
• Surgical procedures – Any necessary operation is covered.
• Medical devices –Implants, pacemakers, and prosthetics if required during a surgical procedure.

Daycare Procedures (Treatments that don’t need 24-hour hospitalization, such as: )

• Cataract surgery
• Dialysis
• Chemotherapy & radiotherapy
• Tonsillectomy
• Sinus surgeries
• Hernia repair

(The above treatments are indicative and vary from insurer to insurer.)

Other covered expenses include:

• Emergency Road ambulance – If you need emergency transport to a hospital.
• Domiciliary hospitalization – If you need to be treated at home due to medical necessity.
• Organ donor expenses – Covers the cost of harvesting an organ from a donor when you are the recipient. However, the donor’s pre- and post-hospitalization expenses are not covered.
• AYUSH treatment – Inpatient treatment under Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH) is covered in registered AYUSH hospitals.

Pre-& Post-Hospitalization Expenses

• Pre-hospitalization – Covers tests, doctor consultations, and medicines before hospital admission (usually 30/60 days)
• Post-hospitalization – Covers follow-up visits, rehabilitation, and medicines after discharge (usually 60/90/180 days)

Optional Add-ons & Enhancements

• Cumulative Bonus – If you don’t make a claim in a year, your sum insured increases (typically by 10% annually, up to a max limit).
• Restore Benefit – Covers follow-up visits, rehabilitation, and medicines after discharge (usually 60/90/180 days)
• Psychiatric treatment with a sub-limit
• Maternity coverage
• Annual Health check-up
• Optical coverage
• Dental coverage
• Emergency Air Ambulance

Note: The information provided herein is for general informational purposes only and is intended to serve as an illustrative guide. Specific document requirements, notification time frames, and procedural details may vary significantly between different insurers and policies. This summary is not intended to be comprehensive or a substitute for the actual policy wording. For precise and up-to-date information, please refer to your insurer’s official policy documents or contact them directly.

Health insurancepolicies often include cost-sharing features like deductibles, excess, and co-payments, which determine how much you’ll have to pay before or along with your insurer’s contribution.

Understanding these terms can help you choose the right policy and avoid surprises during claims.

A deductible is a fixed amount you must pay out-of-pocket before the insurer starts covering medical expenses.

Type of Deductible

The type of deductible usually differs from one insurer to another, and fall among the below types:

• Compulsory Deductibles: - This is a fixed amount determined by the insurer that you must pay at the time of an event or claim. It's non-negotiable and is designed to ensure that policyholders share the costs with insurers.


• Voluntary Deductibles: - Voluntary deductibles are for policyholders who are willing to bear a larger portion of the claim orare doing so to lower their premiums by agreeing to a higher deductible. If you choose this option, you agree to a larger out-of-pocket payment at the time of claim.


• Aggregate Deductibles: - Aggregate deductibles are different from a typical per-claim deductibles, which apply separately to each claim.An aggregate deductible is calculated cumulatively over a specific period, usually a policy year.This means that over the course of a policy year, the insuredis required to bear a specified total amount out-of-pocket for all claims combined before the insurer starts contributing.


• Cumulative Deductibles: - Cumulative deductibles apply to family floater health plans. In this type, a family is insured under one policy with a shared deductible. The total deductible is cumulative, meaning it's spread among all family members. This option is often more cost-effective for families, as it allows them to cover multiple individuals under a single plan.

• A co-payment (co-pay) is a fixed percentage of the medical bill that you must always pay, while the insurer covers the rest. Unlike deductibles (which are fixed amounts), co-pay is a percentage-based cost-sharing agreement.

Types of Co-Pay

Age-Based Co-Pay: As you age, the likelihood of medical issues increases, leading to higher treatment costs. To offset this risk, insurers often include mandatory co-pay requirements - usually for senior citizens. This ensures that older individuals can still access coverage, even as healthcare expenses rise.

Hospital Network Co-Pay: If you choose a hospital outside your insurer’s network, a higher co-pay may apply to reimbursement claims. However, if you opt for a network hospital, you can usually avail of a cashless claim with no co-pay. This is to encourage policyholders to seek treatment at partner hospitals where insurers have pre-negotiated rates..

Medical Condition-Based Co-Pay: Some policies include mandatory co-pay for specific illnesses such as critical conditions or pre-existing diseases. Since treatments for these conditions are typically expensive, insurers require policyholders to bear a fixed percentage of the cost to help manage financial risk.

Location-Based Co-Pay: : Medical expenses are generally higher in metro cities than in smaller towns. To account for this, insurers may apply a co-pay for claims made in high-cost urban areas while keeping co-pay lower (or zero) in smaller towns and rural regions.

• A sub-limit is a cap on how much the insurer will pay for specific medical expenses, even if your total sum insured is much higher.

For example: Psychiatric treatments may be covered under your health insurance plan up to a maximum amount (sub-limit) of ₹ 30,000, even if your overall sum insured is much higher.

Some common Sub-Limits in Health Insurance:

• Room Rent Capping - Many policies restrict room rent (e.g., ₹5,000 per day or 1% of the sum insured per day). If you opt for a higher category room, you may have to pay the difference plus a proportionate deduction on associated expenses like doctor fees and surgery costs.


• ICU Charges - Some policies cap ICU charges (e.g., 2% of sum insured per day).


• Surgery-Specific Limits - Certain procedures (e.g., cataract surgery, knee replacement) may have a fixed reimbursement limit, even if your total sum insured is high.


• AYUSH Treatment Limit - If your policy covers alternative medicine treatments, there might be a sub-limit on how much you can claim


• Ambulance Charges - Many policies cap ambulance coverage (e.g., ₹2,000 per hospitalization).


• Maternity Benefits - If included, maternity coverage usually has low sub-limits (e.g., ₹50,000 for normal delivery, ₹75,000 for C-section).

• A waiting period is the specified time after your health insurance policy starts during which certain conditions or treatments are not covered.

Some waiting periods in a health insurance policy usually are:

• Pre-Existing Diseases (PED) Waiting Period
  • Duration: Generally 24 or 36 months from the policy’s start date (unless the Policy Schedule specifies a different period).
  • Coverage: Expenses for treating a pre-existing condition and its direct complications are not covered during this period.
  • Enhancements: If you increase your sum insured later, the waiting period applies again for the additional amount.
  • Portability Benefit: If you maintain continuous coverage (as defined under IRDAI portability norms), the waiting period may be reduced based on your prior coverage.
  • Declaration Requirement: After the waiting period, coverage for pre-existing diseases kicks in only if these conditions were declared and accepted at the time of application.

• Specified Disease/Procedure Waiting Period
  • Duration: A 24month waiting period(unless the Policy Schedule specifies a different period) applies for the treatment of certain listed conditions, surgeries, or procedures.
  • Accident Exception: This waiting period does not apply to claims arising from accidents.
  • Enhancements: Similar to pre-existing conditions, if you enhance your sum insured, the waiting period resets for the increased amount.
  • Portability Benefit: If you maintain continuous coverage (as defined under IRDAI portability norms), the waiting period may be reduced based on your prior coverage.
  • Overlap with PED: If a specified disease also falls under the pre-existing conditions category, the longer waiting period will be enforced.
  • Continuous Coverage Benefit Continuous coverage (without any break, as per IRDAI norms) can reduce the waiting period, reflecting your previous coverage history.
  
  
  • 30-Day Initial Waiting Period
    • Duration: The first 30 days from the policy’s commencement are subject to a waiting period.
    • Coverage: Any illness occurring within these 30 days is not covered, except for claims arising from accidents (if accidents are covered by your policy).
    • Renewal Benefit: This 30-day waiting period does not apply if you have maintained continuous coverage for more than twelve months.
    • Enhanced Sum Insured: When the sum insured is increased, this waiting period also applies to the enhanced portion.
    
    

    Understanding these waiting periods is crucial as they determine when you can start claiming for specific conditions. Continuous coverage and policy portability may help reduce waiting periods, ensuring that your coverage becomes more comprehensive over time.

    Note: The information provided herein is for general informational purposes only and is intended to serve as an illustrative guide. Specific document requirements, notification time frames, and procedural details may vary significantly between different insurers and policies. This summary is not intended to be comprehensive or a substitute for the actual policy wording. For precise and up-to-date information, please refer to your insurer’s official policy documents or contact them directly.

While health insurance covers a broad range of medical expenses, certain treatments and situations are excluded from coverage. Exclusions ensure that policies remain financially viable while discouraging unnecessary or high-risk claims.

Standard Exclusions:These are exclusions that apply to all policyholders, regardless of age or health condition.

• Diagnostic & Evaluation Procedures – Hospital admissions for diagnostic tests alone are not covered unless followed by active treatment.
• Rest Cure & Rehabilitation (Excl05) – Admissions solely for bed rest, rehabilitation, or respite care (including custodial care or terminal illness care) are not covered.
• Obesity & Weight Control – Bariatric surgery is only covered if medically necessary, based on BMI and severe co-morbidities.
• Gender Transition Treatments – – Expenses related to gender reassignment surgery or hormone therapy are excluded.
• Cosmetic or Plastic Surgery – – Aesthetic procedures are excluded unless required due to an accident, burns, or cancer.
• Hazardous Activities – – Treatment for injuries sustained during adventure or professional sports (e.g., skydiving, racing, mountaineering) is excluded.
• Breach of Law– – Claims arising from unlawful activities or criminal intent are not covered.
• Excluded Providers – – Treatment from blacklisted hospitals or doctors is excluded unless it’s an emergency or life-threatening situation.
• Alcoholism & Drug Abuse – – No coverage for conditions arising due to alcohol, drugs, or substance abuse.

• Alternative & Non-Medical Treatments such as:
  • Treatments in health resorts, spas, or nature cure clinics.
  • Over-the-counter dietary supplements, vitamins, and minerals unless prescribed.
  • Eye treatments for refractive errors below 7.5 diopters.
  • Experimental treatments lacking strong medical evidence.
• Sterility & Infertility – No coverage for contraception, IVF, surrogacy, or sterilization reversal.
• Maternity – Normal childbirth, C-sections, and miscarriages (unless accident-related) are excluded unless specified otherwise.

Specific Exclusions:

• War & Nuclear Exposure – No coverage for war, biological/nuclear attacks, or military service-related injuries.
• Self-Inflicted Injuries & Suicide Attempts – Any injury due to self-harm or attempted suicide is excluded.
• Military & Defense Operations – No coverage for injuries sustained during military or air force operations.
• Sleep Disorders & General Debility – Investigative treatments for conditions like sleep apnea, chronic fatigue, or exhaustion are excluded.
• Congenital External Diseases – Birth defects that require medical treatment may not be covered unless specified in the policy.
• Stem Cell Harvesting – Procedures related to stem cell storage and transplantation are typically not covered unless explicitly included.
• Non-Medical Expenses – Charges for food, toiletries, laundry, and personal items in hospitals are not covered.
• Outpatient & Lifestyle-Related Expenses such as:
  • Routine dental, vision, and hearing aids.
  • Hair loss treatments, wigs, and baldness-related procedures.
  • Prosthetics and medical devices unless used during surgery.

Note: The information provided herein is for general informational purposes only and is intended to serve as an illustrative guide. Specific document requirements, notification time frames, and procedural details may vary significantly between different insurers and policies. This summary is not intended to be comprehensive or a substitute for the actual policy wording. For precise and up-to-date information, please refer to your insurer’s official policy documents or contact them directly.

When you need to make a claim on your health insurance policy, it’s important to follow the proper procedure to ensure that your claim is processed smoothly and efficiently. Below is a detailed guide outlining the steps for both cashless and reimbursement claims, whether you’re in India or outside the country.

• Notification of Claim

Notification of a claim is the initial step where you inform your insurer about your hospitalization or treatment. This prompt communication is essential for a smooth claims process.

a) When to Notify:

• Emergency hospitalisation: Within 24 hours of admission or occurrence of the emergency
• Planned hospitalization: At least 48 hours prior to admission in a hospital or decision to avail treatment.

b) How to Notify:

As soon as you are admitted or receive treatment, contact your insurer’s claims department. Many insurers provide a dedicated helpline, email address, or mobile app for this purpose.

c) Information to Provide:

• Your Policy Number
• Name(s) of the Insured Person(s)
• Date and time of admission or treatment
• Name and address of the hospital or treatment center
• Brief details about the illness or injury

Timely notification ensures that the claim process begins without unnecessary delays.

• Procedure for Cashless Claims

If you choose to receive treatment at a network hospital, you can avail of the cashless facility. The process is as follows:

a) Pre-Authorization Process:

• Initiation: The Network Provider (hospital) will obtain the necessary information from you or the policyholder and submit a Cashless Facility request using the cashless request form available with them.
• Verification: Upon receiving the request form and related medical information, the insurer reviews your policy details and issues a pre-authorization letter to the Network Provider after verification.

b) At Discharge:

• You must verify and sign the discharge papers along with the final bill.
• You are responsible for paying any non-medical or inadmissible expenses.

c) Denial of Cashless Access: If you are unable to provide the required medical details or if pre-authorization is denied, you may still obtain treatment as advised by your doctor and later submit the claim documents for reimbursement.

• Procedure for Reimbursement Claims

If you receive treatment at a non-network hospital or opt not to use the cashless facility, follow these steps:

a) Payment: Settle the hospital bill at the time of discharge.

b) Submission Time Frames:

• Hospitalization, Day Care Treatment, or Pre-Hospitalization Expenses: Submit your claim within 30 days of the date of discharge.
• Post-Hospitalization Expenses: Submit your claim within 15 days from the completion of post-hospitalization treatment.

c) Filing the Claim: Complete the insurer’s claim form accurately and attach all required documents. Submit the complete package within the prescribed time limits.

• List of Documents Required for a Reimbursement Claim

Ensure your claim is supported by the following documents:

a) Duly Completed Claim Form

b) Photo ID and Age Proof

c) Hospital Registration Details: A copy of the Hospital’s Registration Certificate or Registration Number if the hospitalization is in a non-Network Provider, or a certificate from hospital authorities listing available facilities (e.g., number of beds)

d) Discharge Documents: Discharge Card, Day Care Summary, or Transfer Summary

e) Final Hospital Bill: All original deposit and final payment receipts, including refund receipts if an advance was refunded

f) Consultation Papers: Previous consultation records indicating your medical history, treatment details for the current illness, and advice for the current hospitalization

g) Diagnostic Reports: All diagnostic reports (imaging and laboratory) along with the medical practitioner’s prescription and the invoice/bill with receipt from the diagnostic center

h) Medicine/Pharmacy Bills: All pharmacy bills along with prescriptions

i) Any Other Relevant Document: As required by the insurer for assessment of the claim

By adhering to the above procedures and ensuring timely notification and comprehensive documentation, you can help expedite the processing of your claim and secure reimbursement for your medical expenses efficiently.

Note: The information provided herein is for general informational purposes only and is intended to serve as an illustrative guide. Specific document requirements, notification time frames, and procedural details may vary significantly between different insurers and policies. This summary is not intended to be comprehensive or a substitute for the actual policy wording. For precise and up-to-date information, please refer to your insurer’s official policy documents or contact them directly.