You are on page 1of 35


An overview of Health Policies

New issues in
Heath portfolio 2014.


IRDA s Health Insurance Regulations came into force
in 2013.
Consequently All Health Insurance (Mediclaim) Policies
not in line with above new regulations are withdrawn
and new Mediclaim Policies (both Group and
Individual) are introduced from 1
Oct 2013.
National Insurance introduced its own new Mediclaim
W E F 1.9.2013 compliant with new IRDA Health
Insurance Regulations 2013.
IRDA standardised many Health Terminology
definitions and Claim procedures and TPA Role and
* may vary from each Company.
New Features :
Grace Period is now 30 Days in case of Renewal
with gap for all Mediclaim policies.
Free Look Period (FLP)is introduced. All policies
contain 15 days FLP. If policy is not as per Insureds
requirements he can return the Policy in FLP and if no
Claim is made, refund of Premium is given pro-rata but if
risk not commenced then refund allowed after deduction
of Pre- Acceptance Medical Exam Exp and Stamp duty
etc only.
A big and Comprehensive List of 199 Expenses
Generally Excluded in the Policy are given in the
Policy as Annexure. These are detailed very clearly as
Not Payable or Payable subject to limits spelt out for
each item of Exp.
New Features :
Major Health Terminology Definitions are put in policy as
per IRDA Definitions, such as Cashless Facility, OPD,
Network Provider, Pre-Existing Diseases, Portability,
Grace Period, Day Care Treatments, and PPN etc.
Inclusion of Cover for Ayurveda and Homeopathy
Treatment up to 20% of SI.*
Time Limits for submission of Claim Documents and
Documents required for settlement of Claims are spelt
out in Policy Condition clearly. Time Limits for
Settlement or Repudiation of Claim and Provision for
Payment of interest (@ 2% above Bank rate) for delayed
Payments etc are now included in a Policy Condition.
Policy cancellation/Renewal of Policy not to be denied
* may vary from each Company.
New Features :

50% Cost of Pre-Acceptance Medical Examination
Exp is to be reimbursed by the Insurer(NIC), as
per new health regulations.

Different policies in Health Insurance-
---- Class rated

Class rated health policies are of two types- Internal tariff
rated and packaged / customized policies.
Internal tariff rated health policies are the standard policies
sold by by any of our offices with rates, terms and
conditions of cover as set out in the internal guidelines.
These are rule based and underwriting offices have no
authority for deviation. Mediclaim policy, UHIS, Jana Arogya
policy, Parivar Mediclaim, Vidyarthi Mediclaim policy,
Varishta Mediclaim Policy are examples.*
Packaged/ customized health policies are policies specially
designed for individual client or class of clients in terms of
scope of cover, basis of insurance, deductibles, rates, terms
and conditions of cover.
Co branded health policies like Baroda Health , BOI National
Swasthya Bima, V Arogya, SBBJ Medikavach are examples.
The acceptance of these policies are vested with the OOs.*

* may vary from each Company.

Different policies in Health
Insurance----Individual rated

Individual rated health policies are
experience / merit rated. Here the rates,
terms and conditions of cover are
determined by reference to the
requirement of and the actual claim
experience of the insured concerned. This
represent insurances with a high frequency
but low intensity. Group Mediclaim, tailor-
made group mediclaim policies are
Pricing for future with past experience

Parivar policy*
*Family floater Health Insurance policy
*No pre acceptance medical checkup.
*Parents cannot be covered.
*Age from 3mths to 60 years.
*Can be renewed up to 65 years with loading.
* SI from Rs.2 lakhs minimum to Rs.5 lakhs
maximum in multiples of Rs.50,000/-
*sub limits for room rent applicable.
*sublimit of 50% for any one illness.

* may vary from each Company. 9
Parivar policy*
*Any one illness means occurrence of same
illness within 45 days from date of last
* Pre existing diseases Diabetes or/and
Hypertension can be covered at applicable
extra premium loading.
For such claims : 10% co-payment, if
suffering from diabetes or hypertension or
25% co-payment if suffering from both
diabetes and hypertension.

* may vary from each Company.
Medical cover to Senior citizens above the age group
of 60-80 yrs Renewal up to 90 years.
Section I : Hospitalization and Dom hospitalisation-Rs.
1 lakh
Section II: Critical illness cover as a benefit policy-
Rs. 2 lakh
Insured has to bear 10% of each claim payable .
CB available / alternatively discount can be given.
Pre-existing diseases will be covered after one claim
free year of the policy
Diabetes and Hypertension excluding any ailment
already manifested due to the same can be covered
from inception at addl premium
Cost of health checkup available is available after 3
Claims-free years @ 2% of SI.
* may vary from each Company.
National(Individual) Mediclaim
Mediclaim Policy covers insured persons for
their Hospitalisation Medical expenses as in-
patient for major ailments/diseases ,accidental
injuries treatment , including surgical
Ayurveda and Homeopathy Treatments are
admissible up to 20% of S I . No Sub Limits
for these 2 Streams of Medicine.

No Sub Limits for Treatment in PPN Hospitals.
Domiciliary (outpatient)Treatment is not
covered under Mediclaim policies.

Pre existing diseases are covered only after 4
continuous renewals
Entry Age group : 18 years to 65years *
Renewals up to 85+ years
Children above 3 months can be covered if
parents are covered same time.

* may vary from each Company.

National(Individual) Mediclaim
National(Individual) Mediclaim
Maternity Benefits are not covered in individual
mediclaim policy, but can be covered for entire
Group in GMP.
Family Discount of 10% on total premium is
allowable if, spouse , dependent children, or
dependent parents are covered in same policy.
Cumulative Bonus @5% for each claims- free
year of policy. Maximum accumulation of 50%.
For claims 10% reduction in CB.

National(Individual) Mediclaim
Cost of Health Check-up -1% of average SI
without CB, for a block of 4 policy-years
with our company.
Delay in renewals grace period of 30 days
allowed now, only for pre-existing ailments
continuity cover and for CB. But no cover
for gap period.
Excl: 4.2,,30 days waiting period for non
accidental claims(Disease claims) if policy is
new or additional limits opted.

National(Individual) Mediclaim
What is covered

Medical expenses for 24 hrs or more
hospitalization for Non-pre existing ailments or
accidental injuries.
Less than 24 hrs hospitalization if advanced
treatment packages are involved.
No Dental /Cosmetic treatment
Sub limits apply.
Ayurveda and Homeopathy treatments upto
20% of S I. *
Ambulance Charges admissible: up to 1%of SI
Max Rs 2,000 in a Policy Period.*

* may vary from each Company.

National(Individual) Mediclaim
What is covered *

A. Room Rent Boarding Nursing expenses:
Room rent limits: 1% of Sum Insured per day subject to
maximum of Rs.5000/-. If admitted in IC unit 2% of sum
insured per day subject to maximum of Rs.10,000/-.
Over all limit under this Head: 25% of SI per illness.
B. Surgeon Anesthetist Medical practitioner,
consultants special fees. Maximum limit per illness -25%
of SI
C. Anesthesia, Blood, Oxygen, OT charges, Surgical
appliances, medicines, drugs, Diagnostic material &
X-ray, Dialysis, Chemotherapy, Radiotherapy, cost of
pacemaker, artificial limbs and cost of stent and implant.
Maximum limit per illness- 50% of SI.
Any one illness : continuous period of illness and
includes relapse within 45 days from the date of
discharge from date of discharge from the
hospital/nursing home. * may vary from each Company.

Other Important Features

Sum Insured : Rs.50,000 to Rs.5,00,000 in
slabs of Rs.25000/- per head *
No floater cover /first loss policy under
individual Mediclaim.
TPA services are Mandatory
Definition of Hospital , surgical operation ,
post-hospitalization(60 days), pre-
hospitalization(30 days).
ID Cards & Cash-less Hosp. treatments
Reimbursement claims-Non-network
* may vary from each Company. 18
National(Individual) Mediclaim
National(Individual) Mediclaim
Other Important Features

Claims intimation 3 days of
Final claims submission -15 days of discharge
from Hospital /completion of PHC.
We have an Obligation to renew the policy in

National(Individual) Mediclaim

Other Important Features

4.1 : Pre-existing diseases : means Any condition,
ailment, injury or related condition(s) for which Insured
had signs or symptoms and/or were diagnosed and/or
received medical advice/treatment within 48 months
prior to your first policy with us.

Benefits for pre existing diseases will not be available for
any condition(s) as defined in the policy until 48 months
of continuous coverage have elapsed since inception of
the first policy with us.

4.2 : First 30 Days waiting Period for Non-Accidental

National(Individual) Mediclaim
Other Important Features

Exclusion 4.3:
During the first one year : Benign ENT
disorders & surgeries like tonsillectomy
adenoidectomy /mastoidectomy/ tympanoplasty.
During the first two years of policy: cataract,
hysterectomy, hernia,piles,sinusitis,congenital internal
diseases, diabetes, hypertension, calculus diseases etc
During the first four years of policy: Treatment
for joint replacement due to degenerative
conditions, age related osteoarthritis and
If these diseases are pre-existing at the time of
proposal, will be covered only after four
continuous claim free policy years.

Other Important exclusions:

Injuries or diseases caused by war and war like
Circumcision, vaccination, inoculation, cosmetic
treatment, plastic surgery
Spectacles, contact lenses, hearing aids
Dental treatment without hospitalisation
Convalescence, general weakness, congenital, venereal
disease, sterility, self injury or alcohol use AIDS
Diagnostic expenses without any disease
Vitamins and tonics unrelated to treatment
Diseases by nuclear weapons
Naturopathy treatment

National(Individual) Mediclaim

Other Important Features

Policies does have regulatory provisions for a grace
period of 30 days for renewal.

Enhancement of sum insured
S.I. can not be increased mid-term. On renewal if a
request is received, enhancement can be allowed
(I) S.I. up to Rs.5,00,000 Maximum at discretion of
Company, subject to satisfactory Medical check up.

(II) Continuing or recurrent nature of diseases/ complaints
will be excluded from the scope of cover for enhanced

National(Individual) Mediclaim
National(Individual) Mediclaim
Pre-acceptance health check up

Pre-acceptance health check up is mandatory.
for proposers 50 years and above seeking insurance for the first
time as an individual or as a member of family.
- Where there is break in insurance.
- In case of enhancement of SI on renewal.
Pre-acceptance health check up is not mandatory
- if the policy holder submits satisfactory evidence/documents
of having held a health policy of other Insurers without break
- Where the proposer is below 50 years of age.
- For proposers above 50 years of age covered under any Health
Insurance Policy
- Proposers other than above have to undergo pre acceptance
medical check up at their own cost. NIC will reimburse 50%
Exp only. The reports to be submitted are
Physical examination
Blood test, Urine sugar, Blood pressure, ECG, Eye check up
including retinoscopy, Lipid Profile and Serum Creatinine.*

* may vary from each Company.

Group and Tailor-made Policies.
Groups include- employer employee group and non
employer employee groups like employee welfare
association, holders of credit cards issued by a specific
company, customers of a particular business where
insurance is offered as an add on benefit, borrowers of
bank, professional associations or societies where the
president/secretary/manager/group organizer in his
capacity as organizer of the group has an authority from
majority of the members to arrange on their behalf.
In case of non-clarity about a group falling under is to be
referred to IRDA.
A person negotiating group rates and then going around
finding members to insure is considered an illegitimate
Entry or exit of members permitted from well defined
date- anniversary of policy or first of following month.

Group and Tailor-made Policies.
Group health policies provide:
Large numbers and volume
Lower administrative costs
Experience rating
Tailoring of benefits
Group policy or tailor-made policies for group < than
1000 not allowed:
(a) To help guard against adverse selection
(b) Limited scope for risk pooling affecting
sustainability of
the policy.
Probability of high variance by actual claims vis a
vis expected claims.

Group and Tailor-made Policies.
Tailor-making of policies is done to meet with the
specific requirement of claims and for covers not
available in a standard group health policy.
Floater purpose is to increase the number of persons
under coverage of a family- spouse and children.
Floater SI not to be less than Rs 2 lac.
Floater loading not to be less than 15% for spouse
and 10% for each child.
If Parents covered in floater amount loading may be
25% minimum for each parent.
Maternity: Sum insured may be restricted to 20 to
25% of overall SI and not to exceed Rs 50,000/-.Load
15% on premium.

Group and Tailor-made Policies.
Baby day one cover excluding pre birth disabilities-
5% loading.
Waiver of 9 months waiting period: 5% loading
Waiver pre-existing disease: 10%
Waiver of I month waiting and 1/2/4 years waiting:
25% loading for fresh policies.
OPD treatment: 100% loading on sum insured opted.
Addition of domiciliary hospitalization:
Corporate Buffer: 10% on sum insured opted.
Claims loading : as if 70% basis or rating on outgo
basis+TPA+Procurement costs+ Management
expenses+ profit

New Issues in Health Portfolio.
TPA Services are by and large compulsory.
New SLAs (Service Level Agreements) are
entered into by NIC with TPAs effective from
Aug 2012. These contain Performance based
Fees payment replacing Fee payment as a % of
Premium charged under Policies.
Claim Intimation Time Limits are imposed.
Delayed Intimations can not be accepted by
TPAs without Company waiver approval.
New TAT (Turn Around Timelines) are
New Issues in Health Portfolio.
PPN System (Preferred Provider Network of
Hospitals)has come into operation in Mumbai,
Delhi, Chennai, Bangalore, Hyderabad, Pune
and Ahmedabad.
In PPN Hospitals, Cashless Treatment is
rendered at Pre-Agreed Tariff rates for most of
the Treatment Procedures. Hospitals are
classified based on infrastructure and scale.
Where Treatment is taken in PPN Hospitals, for
such Claims, Policy Head-wise Sub-Limits are
not applicable.
New Issues in Health Portfolio.
New Covers of TOP-UP and Super TOP-UP are
now in use.
Top-Up Cover is cheaper and works above the
Standard Mediclaim Policy as additional Cover.
Any Single Claim exceeding (per Treatment)
Mediclaim Policy SI Limits will be covered by
TOP-UP policy.
Super Top-Up Cover is little costlier but
cheaper than regular Mediclaim policy. It
covers all treatments above Std Mediclaim
policy, not per Treatment but for all Claims
New Issues in Health Portfolio.
Mortality and Morbidity Studies are being done
to improve the Premium rates for future.
Morbidity.. Disease-wise Data collection, age
wise Morbidity rates and Epidemic and Endemic
Disease spread are being analysed to draw
insights on Morbidity rating patterns.
HIV and AIDS Coverage, in limited way, is
contemplated by IRDA as a new measure in
better coverage provisions with Medical
advancements in the research field.
Non-Allopathy streams of Medical treatments
are now being considered for reimbursements.
New Issues in Health Portfolio.
Portability is now introduced. At renewal time
Insured can switch-over to a New Health
Insurer with similar benefits and Coverage.
45 days Prior Notice in Writing by Insured has
to be given to Existing Insurer for such Switch-
over and New Insurer can give benefit of
Continuing Covers and Benefits only upon
receiving Outgoing Insurers Confirmation and
approval for Portability request received in
Portability is subject New Insurers Entry age
and SI limits etc. for each policy request.
New Issues in Health Portfolio.
Portability is applicable to Individual Mediclaim
policies and Floater Policies other than Group
Policies. At Renewal only this Option can be
Individuals under Group Policies can switch
over to Individual policies and One Year there
after can use Portability Option.
Portability is a right given to Insured to have
the Benefit of Number of Years Policy is taken
for Waiver of PED Cover Exclusions. And also
entitlement for Cumulative Bonus and up to
outgoing Policy S I.
K Sankara Narayana
Manager NIC HRO
Jan 2014
6 th Jan 2014.