Health Insurance

List of Common Health Insurance Terms in India

1. Health Insurance

   Health insurance is a type of insurance coverage that pays for medical and surgical expenses incurred by the insured individual. It provides financial protection against unexpected medical costs.

2. Insured

   The insured refers to the individual or group covered by the health insurance policy. This person is eligible to receive benefits as per the terms and conditions of the policy.

Insurer

An insurer, also known as the insurance company or the health insurance provider, is the organization that offers the health insurance policy and agrees to provide coverage and benefits to the insured in exchange for premium payments.

Premium

The premium is the amount paid by the insured to the insurer at regular intervals (monthly, quarterly, or annually) to maintain the health insurance coverage. It is the cost of the insurance policy.

Sum Insured

The sum insured, also known as the coverage amount or the policy limit, is the maximum amount that the insurer will pay for medical expenses and treatments covered under the policy. It is usually defined on an annual basis.

Pre-existing Conditions

A pre-existing condition refers to any illness, injury, or medical condition that an insured individual had before purchasing the health insurance policy. Depending on the policy terms, coverage for pre-existing conditions may be subject to waiting periods or exclusions.

Waiting Period

The waiting period is the specified period after purchasing the health insurance policy during which certain benefits, such as coverage for pre-existing conditions or specific treatments, may not be available. Waiting periods vary among policies and insurers.

Network Hospitals

Network hospitals are healthcare facilities (hospitals, clinics, diagnostic centers, etc.) that have a tie-up or agreement with the health insurance provider. Insured individuals can avail of cashless treatment or reimbursement for expenses incurred at these network hospitals as per the policy terms.

Cashless Treatment

Cashless treatment is a facility provided by health insurance companies, where the insured individual can receive medical treatment at a network hospital without paying upfront. The insurer settles the payment directly with the hospital, subject to policy terms and conditions.

Co-payment

Co-payment is a cost-sharing arrangement where the insured individual agrees to pay a percentage of the medical expenses, while the insurer pays the remaining percentage. For example, if the policy has a 20% co-payment clause, the insured will pay 20% of the medical bills, and the insurer will pay the remaining 80%.

Deductible

A deductible is the initial amount that the insured individual is responsible for paying before the insurance coverage begins. It is usually a fixed amount specified in the policy. Once the deductible is paid, the insurer covers the remaining eligible expenses, up to the sum insured.

Exclusions

Exclusions refer to the medical conditions, treatments, or circumstances that are not covered by the health insurance policy. It is important to review the policy document to understand the exclusions and limitations of the coverage.

AYUSH Treatment

AYUSH treatment refers to a holistic approach to healthcare that incorporates traditional and alternative systems of medicine such as Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy to promote wellness and treat various ailments.

Bariatric Surgery

Bariatric surgery is a surgical procedure that helps individuals with severe obesity achieve significant weight loss by reducing the size of the stomach or by altering the digestive process. It aims to improve overall health, manage obesity-related conditions, and enhance quality of life.

Claim

In health insurance, a claim is a formal request made by the insured individual or healthcare provider to the insurance company for reimbursement or coverage of medical expenses incurred by the insured individual. It involves submitting relevant documents, such as medical bills and treatment records, to support the request for payment or coverage.

Day Care Procedures

Day care procedures in health insurance refer to medical treatments or surgeries that can be completed within a single day without the need for overnight hospitalization. These procedures are typically covered by health insurance policies and may include diagnostic tests, minor surgeries, chemotherapy sessions, or certain specialized treatments.

Dependent

In health insurance, a dependent refers to a person who relies on the primary policyholder for financial support and is eligible for coverage under the policy. Dependents are often immediate family members, such as spouses, children, or parents, and they are entitled to receive benefits and access healthcare services as specified in the policy.

Domiciliary Treatment

Domiciliary treatment, also known as home healthcare, refers to medical treatment provided to a patient at their residence when hospitalization is not possible or required. It may include doctor visits, nursing care, diagnostic tests, and administration of medication, which are covered by health insurance under specific conditions and limits.

Minimum Entry Age

Entry age in health insurance refers to the age at which an individual is eligible to purchase a health insurance policy. It signifies the minimum and maximum age limits within which an individual can apply for coverage, and it can vary based on the insurer and the specific health insurance plan.

Maximum Entry Age

Entry age in health insurance refers to the age at which an individual is eligible to purchase a health insurance policy. It signifies the minimum and maximum age limits within which an individual can apply for coverage, and it can vary based on the insurer and the specific health insurance plan.

Grace Period

Grace period in health insurance refers to the specified period of time after the premium due date during which the policy remains active, even if the premium payment is delayed. It allows the insured individual to make the payment without the policy lapsing, ensuring continued coverage.

Family floater

Family floater in health insurance is a type of policy that provides coverage for the entire family under a single sum insured. It allows family members to share the coverage limit, providing flexibility in utilizing the insurance benefits for any member who needs medical treatment.

Free Look Period

Free look period in health insurance is a specified period of time after purchasing a policy during which the insured can review the terms and conditions. If dissatisfied, they can cancel the policy and receive a refund of the premium paid, subject to certain conditions and deductions as per the insurer's policy.

Indemnity Plan

An indemnity plan in health insurance is a type of policy that reimburses the insured for the actual medical expenses incurred. It allows the insured to choose any healthcare provider and provides coverage for a percentage of the actual expenses, subject to policy limits and deductibles.

No Claim Bonus

No Claim Bonus (NCB) in health insurance is a reward offered to the policyholder for not filing any claims during a policy year. It provides a discount on the premium or an increase in the sum insured as an incentive for maintaining good health and not utilizing the insurance coverage.

Portability

Portability in health insurance refers to the ability of an insured individual to switch from one insurance provider to another while retaining the existing policy benefits, such as waiting periods and coverage for pre-existing conditions. It allows individuals to transfer their health insurance policy without losing the accumulated benefits or continuity of coverage.

Preventive Health Check-up

In health insurance, preventive health check-up refers to a provision or benefit that covers the cost of regular medical examinations, screenings, and tests aimed at detecting diseases or risk factors at an early stage. It encourages proactive health management and can help identify potential health concerns before they become more serious or costly to treat.

Restoration Benefit

Restoration benefit, in health insurance, is a feature that reinstates the sum insured or coverage amount if it gets fully exhausted during a policy year due to claims. It provides an additional coverage amount for subsequent claims within the same policy year, ensuring continued financial protection for the insured individual or family.

Riders/ Add-on Covers

Riders or add-on covers in health insurance are optional supplementary benefits that can be purchased along with the base health insurance policy to enhance the coverage. They provide additional specific benefits such as critical illness coverage, maternity benefits, or accidental disability coverage, tailored to the insured individual's needs, for an extra premium.

Room Rent Limit

Room rent limit in health insurance refers to the maximum amount or percentage of the hospital room rent that will be covered by the insurance policy. If the room rent exceeds the specified limit, the insured individual may be required to bear the additional expenses or may face a proportionate reduction in other benefits.

Sub-limits

Sub-limits in health insurance are predetermined limits placed on specific medical expenses or services, such as room rent, doctor's fees, or certain treatments, that restrict the maximum amount payable by the insurance company for those particular items. They are often mentioned as a percentage or a specific amount of the total sum insured and can impact the reimbursement or coverage provided for those specific items.

Top-up Plan

A top-up plan in health insurance is an additional coverage option that provides an extra sum insured beyond the deductible limit of an existing base health insurance policy. It offers financial protection against high medical expenses by covering costs once the deductible is exceeded, either on a per-claim basis or in aggregate over a policy year.

Underwriting

Underwriting in health insurance is the process of evaluating and assessing the risk associated with an individual or group seeking insurance coverage. It involves reviewing medical history, current health status, and other relevant factors to determine the insurability and premium rates for the applicant.