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The terms, coverages, exclusions, rating and underwriting practices of Health Insurance, Personal accident & Critical Illness vary among the companies The details mentioned here reflect only the general approach of the insurers
Health Insurance provides coverage for the medical expenses of the admissible claims
Individual Mediclaim Policy Group Mediclaim Policy
To cater to the varying and increasing needs, different forms of Health Insurance covers are available Medical examination may be required in some cases based on the age & Sum Insured opted Health insurance operates in two ways Cashless & Reimbursement
Individual Mediclaim Policy: Individuals are granted this cover Provides cashless/reimbursement of hospitalisaion expenses for illness / disease / injuries sustained during the policy period within India The maximum liability per person cannot exceed the individual Sum insured
Individuals within the agegroups specified by the insurance companies can take the policy Normally companies put a waiting period of one month Family Discount is also provided Some insurance companies grant floater cover also for families For Claim free renewals, insurance companies grant cumulative bonus
Some of the coverages provided by the insurance companies include;
Expenses related to;
Room, Boarding expenses in the Hospital / Nursing Home Nursing Expenses Surgeon, Anasthesia, Medical practitioner, Consultant, Specialist Fees
Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines and Drugs, Diagnostic Materials, X- Ray, Dialysism Chemotherapy, Radiotherapy, Cost of pacemaker and similar expenses
Claims are admissible only when treatment is taken in a hospital/nursing home which satisfies the criteria as per the policy wording
Expenses on hospitalisation for a minimum period of 24 hours are admissible However this time limit is not applicable to certain treatments (for eg Dialysis, Chemotherapy, Kidney stone removal etc.) Pre & Post hospitalisation charges as specified in the policy wording, are also covered
Some of the exclusions are;
All diseases/injuries which are pre-existing when the cover incepts for the first time Diseases contracted during the first 30 days from the commencement of the policy, except those which are stated separately in the schedule Certain diseases like Hernia, Cataract, Sinusitis etc are not covered during the first year of the policy
Claims as a result of War, Nuclear weapons materials Cost of spectacles, contact lenses, hearing aids Dental treatment or surgey of any kind unless due to accidents and require hospitalisation Congenital diseases, AIDS, use of intoxicating drugs, alcohol intentional Self injury, vaccination pregnancy, childbirth (can be covered if maternity benefit is selected)
Schedule of the policy: The policy schedule incorporates the following details of all the persons to be covered, apart from the usual details like name, address etc Name Age Gender Relationship with the insured Occupation Sum insured Premium
Sum Insured & premium: Various SI Options are available Separate premium rates are charged for the various age groups The premium rates are related to the age of the persons and the Sum insured opted
Proposal form: Elicits a detailed information relating to Name, address, DOB, Gender, Relationship with the insured, monthly income, medical conditions, previous claim details etc In case of adverse medical history, the insured has to complete a detailed medical questionnaire also These forms are scrutinised by the panel doctors and based on their opinion acceptance, exclusions, terms etc are decided
Group Mediclaim policy
GMC Policies are issued for group of individuals GMC Policy is available for any group /association/instituition/corporate body provided it has a central administration body and minimum no of persons to be covered
Coverages are same as that of Individual mediclaim policies, with few differences It is not permissible to issue unnamed policy There will be no family discount, cumulative bonus etc Group discounts are available based on the group size Renewal premium is subject to bonus/malus clause Insurance companies now offer extensions like maternity benefit, Preexisting disease waiver, Waiting period waiver etc.
PERSONAL ACCIDENT INSURANCE
The purpose of Personal Accident is to pay fixed compensation for death or disablement resulting from accidental bodily injury Policy forms and rating system used by the companies are not uniform but follow similar approach with minor variations
Types of disablement: Permanent Total Disablement Permanent Partial Disablement Temporary Total Disablement
Permanent Total Disablement
The disablement is permanent and irrecoverable and is absolutely total ie, the insured is prevented from engaging in gainful employment of any kind Eg: Paralysis, loss of sight of both eyes, loss of limbs
Permanent Partial Disablement:
Similar to PTD but diablement is not total but is only partial. Eg: Loss of finger The percentage of compensation is as per the table mentioned in the policy schedule For eg the table specifies that for loss of little finger the compensation is 4% of the SI, loss of four fingers 35% etc
Temporary Total Disablement The disablement is total but for a temporary period only Weekly benefits are payable (Usually 1% of
the Sum Insured up to the specified limits and period)
Benefit Chart A table of benefits specifying the amounts of compensation payable in the event of happening of various contingencies
Carriage of dead body Education fund for the dependant children Cumulative bonus Family discount Medical expenses incurred in connection with bodily injury can also be covered on payment of extra premium
The main factor used for PA Rating is the occupation The Premium differs in case of different risk levels determined by your occupation
Risk Level I :
Administrative / managing functions, accountants, doctors, lawyers, architects, teachers and similar occupations
Risk Level II :
Manual labour, garage mechanic, machine operator, paid driver (car / truck / heavy vehicles) cash carrying employee, builder, contractor, veterinary doctor and similar occupations.
Risk Level III:
Workers in underground mines, electric installations with high tension supply. Jockey, circus performers, big game hunters, mountaineers, professional river rafters and similar occupations
Some of the exclusions commonly found in PA Policies are;
Accidental bodily injury due to:
Suicidal attempts, self-inflicted injury, pregnancy or child birth While under the influence of liquor or drugs: Through deliberate or intentional, unlawful criminal act, error or omission.
Consequential losses of any kind War and allied perils and nuclear risks
The PA proposal form elicits information on the following: Personal Details - Age, height, weight, occupation, monthly income Physical Condition Habits & Past times Past claim history Previous accidents or diseases Selection of benefits and sum insured (The SI is
compared with the monthly income)
Group Personal Accident Policies: Issued to groups There should be a common relationship among the persons to be insured There should be a central point of administration for the policy scheme
GPA Policies can be granted to groups
With Employer-Employee Relationship
( Firms, Companies etc)
Without Employer-Employee Relationship
(Associations, Societies, Clubs etc)
The coverages of GPA Policies are similar to that of individual PA Policy Cumulative bonus, Family discount & Education grant do not apply Group discounts are possible Bonus / Malus may be applied during renewals
CRITICAL ILLNESS INSURANCE
Critical illness policy provides protection from the life threatening illness, which can hamper the routine life style. With a critical illness cover the insured can secure his life from such contingencies.
Critical Illness is a benefit policy which pays the SI as lump sum amount once the insured is diagnosed with one of the listed critical illness . Irrespective of the medical expenses, the lumpsum benefit is provided
The critical Illness policy covers major illnesses like; Cancer Paralysis Coronary Artery Bypass Surgery Major Organ Transplant First Heart Attack Stroke Kidney Failure
Medical examination may be required in some cases based on the age and the benefit amount opted
Some of the common exclusions are;
Any critical illness for which care, treatment, or advice was recommended or which was first manifested or contracted before Any critical illness diagnosed within the waiting period Presence of HIV/AIDS infection Treatment arising from or traceable to pregnancy or childbirth including caesarean section, birth defects War & war like perils Consequential losses of any kind,loss of opportunity, loss of gain, business interruption etc
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