Glossary

Add-ons/Riders

Add-ons or riders, are the extra benefits that you can opt for in your insurance policy by paying an additional amount. For example, air ambulance facility or the critical illness cover may not be covered in your policy, but you can avail these as riders. We suggest you check these benefits & choose relevant ones as required by you, before making payment.

You can also speak to Benefits Circle Support team for better understanding of the benefits of the add-ons/riders.

Beneficiary

The person nominated in the insurance policy to receive the insurance benefit in the unfortunate event of the death of the insured is called a beneficiary. It is prudent to appoint nomination in the policy.

Outpatient Treatment

This kind of treatment means that the insured person visits a particular department or a medical facility or a hospital or a nursing home in order to get some medical care regarding diagnosis or medical condition the insured person is already facing by a medical practitioner. Here the insured person is not admitted to the hospital, or treated under in-patient and day care categories.

Claim settlement ratio

Claim Settlement Ratio (CSR) is a number indicating the percentage of insurance claims the insurer has settled during the previous financial year. In general, Claim Settlement Ratio of an insurer is viewed as an indicator of its overall claim-solvability and risk management ability. The higher the Claim Settlement Ratio of an insurance company, the better it is.

Claim Settlement Ratio = (Total no. of Claims Approved/Total no. of Claims Received) x 100

This result is represented in the form of a percentage. Let us assume that an insurance company has a Claim Settlement Ratio of 99.01%. This means that the insurer has settled and paid out 99.01% claims out of the 10,000 claims filed with them.

Convalescence Benefits

When recovery from disease and hospitalization is prolonged, insurance providers provide a lumpsum cash benefit to the insured, which can help them overcome any loss of income arising due to hospitalization. This benefit is known as convalescence benefit or recovery benefit and is applicable when the patient is hospitalized for more than 7 to 10 days.

Example: Pooja meets with an accident and is hospitalized for two weeks. Due to prolonged hospitalization, she must take an extended leave from work and faces the loss of pay. As her policy entitles her to convalescence benefit, she can utilize the benefit to recover from the financial loss faced by her due to the long hospitalization and recovery period.

Cumulative bonus

For every year that you do not place any claim with the insurer, you get a cumulative bonus. It is usually in the form of an increase in the health cover. For example, your health policy may offer you a cumulative bonus of 10% for every claim-free year, which would mean that your sum assured will increase by 10% every year in case of no claims. We suggest you go through the policy details and check the maximum limit of the cumulative bonus.

Free look period

Free-look period indicates a time period during which you can return the policy if you feel that this is probably not what you wanted. This feature is effective from the moment you receive the policy document till the 15th day. If you are not satisfied, you can return the policy within the same time period.

You have to communicate to the insurance company in writing about it. The premium refund will be adjusted for proportionate risk premium for the period on cover, expenses incurred by the insurer on medical examination, and stamp duty charges.

Type of Health Insurance Plan:

Health insurance products come in different types for different needs. Check the policy terms to know what type of health plan you are buying.

1. Individual health insurance policies
   These plans cover medical expenses for injury, accidents, medicines, room rent, etc., for one individual only.
2. Family floater health insurance policies
   Instead of buying separate insurance policies for different family members, one can get a single-family floater policy covering the entire family.
3. Group/employee health insurance policies
   Employers of medium to large size enterprises buy these plans for their employees.
4. Senior citizen health insurance policies
   These health plans come with higher premiums but offer full coverage and high sum insured, ideal for senior citizens.
5. Critical illness benefit plans
   These policies provide a high insured lump sum for certain life-threatening diseases such as cancer, heart attack, and kidney failure.
6. Personal accident insurance policies
   These provide compensation for disablement, injury or death by unforeseen accidents.

Network hospital

A hospital that provides cashless treatment to you under your health insurance policy is called a network hospital. These hospitals are associated with your insurance provider. You can have your treatment done at any other hospital as well, but there you won’t be able to avail cashless treatment as they are non-network hospitals.

Organ donor cover

In case of a person donating an organ to another, both the donor’s and the recipient’s expenses can be covered under the insurance policy. The surgery and storage of organ are also covered. The cost of surgeries may be prohibitive because it ranges in lakhs. Especially if you have pledged your organs, this cover is worth considering.

Organ donor cover

In case of a person donating an organ to another, both the donor’s and the recipient’s expenses can be covered under the insurance policy. The surgery and storage of organ are also covered. The cost of surgeries may be prohibitive because it ranges in lakhs. Especially if you have pledged your organs, this cover is worth considering.

Policy Period

Policy Period means the time period between the date of commencement and the date of expiry of a policy as mentioned in the schedule

Prenatal

The period leading up to the delivery of a child is called the prenatal period. Now, maternity insurance can mean a range of things when buying a policy; hence it is advisable to read the policy document before you sign up for it. Also, maternity insurance generally has a waiting period of 2-5 years, depending on the policy. Hence, if you are likely to plan a family, the sooner you insure yourself, the better.

Reimbursement claim

When you get admitted to any hospital of your choice for treatment which is not a network hospital associated with your insurance provider, reimbursement claim is the method you adopt for claiming your expenses. It involves you paying to the hospital from your pocket and retaining all the reports, invoices etc. to be produced to the insurance provider after your discharge within a stipulated time.

Room rent

The hospital room rent limit is nothing but the specific amount of rent you pay for staying in a hospital. In case you are required to get hospitalized for a few days. You will occupy a bed or opt for a room in the hospital.

For this service, room charges will be levied on a daily basis. The amount is usually a specific percentage of the sum insured.

For example: If your healthcare plan has a sum insured of Rs. 2,00,000, then the room rent limit will be within the range of 1%-2% of the SI cover (Rs. 2000 to Rs. 4000 per day; this is different from one policy to another).

Third party administrators (TPA)

Third party administrators (TPA) are those authorised by insurance companies to perform various administrative tasks including premium collection, processing, claim settlement, customer service, etc. TPAs are licensed by IRDAI to provide insurance administration service. They charge a certain commission for the services they provide

Claim Settlement Ratio (CSR)

It is the ratio between the number of claims settled and the number of claims received by the insurer.

CSR = Claims settled in a year / Claims received in a year x 100 It is expressed in percentage and used to gauge the claim settlement rate of the insurer.

A higher CSR can mean higher chances of claim settlement. However, CSR should not be the sole factor for selecting an insurer, as you must also consider overall services, policy coverage, etc.

Grace Period

In order to keep a health insurance policy active, all the insurance premiums must be paid before the due date. However, with a busy life which we all have, it is quite obvious to forget the due date for health insurance premium payment. Health insurance companies usually would grant a grace period of around 15 days to 30 days for making the premium payment. If the insurance premium payment is not made within this grace period then the health insurance policy might lapse.

However, if you need to submit a health insurance claim within the grace period, your claim would not be admitted/accepted unless you pay up the due premium first.

Deductible

A deductible is the base amount you mention while opting a super top-up health insurance plan. Once the treatment expenses cross the threshold deductible amount, only then you can file a claim under a super top-up plan.

You as the policyholder can either use your base/corporate health plan as a deductible amount or choose to pay from your pocket. Ideally, a combination of a base/corporate health plan plus a super top-up plan is recommended to increase the coverage in a budget-friendly way. It is advisable to keep the deductible amount equal to the sum insured of your base/corporate health plan, so that you don't have to shell out money from your pocket.

For example, Raj is covered under corporate health plan cover of INR 3 lakhs and buys a super top up health insurance plan cover of INR 10 lakhs by choosing deductible of 3 lakhs. He got hospitalized and his medical bill was 4 Lakhs.

So, the initial amount of 3 lakhs will be paid by the corporate health plan and the remaining amount 1 lakh would be paid by the super top-up health insurance plan.

Suppose, Karan did not have corporate health plan, he would have had to pay the deductible amount from his pocket, i.e. INR 3 lakhs. And only after the exhaustion of the mentioned deductible amount, the super top-up plan would have come for the rescue to cover the rest of the bill amount.

Consumables

Consumables in health insurance are usually medical equipment/aids discarded after use, like PPE kits, gloves, masks, syringes, etc.

Several items classified as consumables may seem relatively inexpensive when purchased as a single item. However, when these are repeatedly used during a procedure or treatment, they might amount to a large portion of the bill. In such a case, having a consumable cover can save you from the financial burden of these consumables.

Often, they were not covered by the health insurance companies earlier. However, with the pandemic, consumables became a significant part of the hospital bill due to increased usage. Insurance policies do provide Consumable Cover as an Add-On that you can add while buying your policy and cover the consumable expenses.

Dependents

A family member for whom an individual is willing to provide healthcare and insurance coverage by adding them to his/her insurance plan is called a dependent. An individual’s spouse, children or parents qualify as dependents. Dependents can be easily added to a policy if the policy is not exclusively designed for individual coverage.

If you wish to add a dependent to your policy, please reach out to your insurance provider, and they would be able to help you with the process for the same.

For single or unmarried individuals, parents can be added as dependents under the family cover. In the case of married persons, the spouse can also be added to the family plan as well as children

Emergency Care

A medical treatment that is not planned and is required due to an unforeseen/unexpected circumstance comes under emergency care. For example, an injury caused due to an accident, can require emergency care and immediate attention.

Exclusions

Your medical policy may not cover each and every disease, medical condition, medical tests etc. So, all such conditions/requirements not covered under a policy are called exclusions. It differs from one policy to another; hence, we suggest you go through the list thoroughly before buying the policy.

Family floater plan

It is a kind of health insurance where more than one member of the same family is covered under the same policy. Under such a policy, you can claim health insurance against treatment for more than one person in your family every year. For example, let's suppose you have a Rs 10 lakh family floater policy. Now, you were hospitalised and the expenses incurred was Rs 3 lakh which was covered by the insurance. The balance of Rs 7 lakh can be used to cover the medical expenses incurred by another family member covered under the policy.

In-patient hospitalization

From a medical insurance point of view, in-patient hospitalization is when you are admitted to a hospital for more than 24 hours. Only then can you avail the hospitalization benefits from your medical policy.

Indemnity

A regular health insurance plan (individual or family floater) that covers your medical expenses and is not related to any specific type of disease is called an indemnity plan. On the contrary, if a health insurance plan covers a certain type of illness, specifically, a critical illness like cancer, then that plan is called the defined-benefit plan.

Maternity Insurance

It is a health insurance feature under which a family can claim the medical expenses related to pregnancy, childbirth and new-born. Some insurers provide maternity insurance as an add-on coverage. However, there are some plans that have maternity coverage in-built in their regular cover with a waiting period of usually 2-3 years.

No claim bonus

Some insurance providers increase your sum insured/health cover by a fixed percentage in case of you not claiming any amount that year. This makes you eligible for a higher health cover at the same premium.

Premium

When you buy a health insurance policy, you pay a certain annual amount to ensure that you can avail the benefits, this amount is known as your insurance premium. For example, hypothetically, you may pay ~Rs 12,000 every year for a health cover of Rs 5 Lakh. At times, if you choose to pay a collective premium of 2-3-5 years, you can avail a discount on certain policies also. We suggest you browse through any such offers before buying the policy.

Portability

Portability is defined as the right of a policyholder having an individual health insurance plan by which he can transfer the credit which he has earned for the pre-existing conditions and other exclusions in case of switching from one insurance provider to another or from one health insurance plan to another plan of the same insurance provider if the health insurance plan has been carried on without any break.

Usually, the portability request needs to be submitted a minimum of 45 days before the due date for the same to be processed.

Pre and post hospitalization

In the case of hospitalization, there are many expenses leading up to the admission and then in the follow-ups after getting discharged, that a patient incurs. These are called pre and post hospitalization expenses, respectively. Most policies cover up to 30 days of pre hospitalization and 60 days of post hospitalization covers; however, it may differ and needs to be checked with the policy document. The kind of expenses covered in pre and post hospitalization covers are also mentioned in the document, for your reference.

Hospital

A hospital / nursing home is an institution in India established for indoor care and treatment of sickness and injuries. The hospital or nursing home should be registered with the appropriate local authority and it should be functioning under the supervision of a registered and qualified medical practitioner. If not, it should satisfy the following criteria:

• It should have at least a minimum of 15 inpatient beds (10 beds in C class towns)
• It should have fully equipped operation theatre in case surgeries are being carried out
• It should have fully qualified nursing staff under its employment round the clock
• Fully qualified doctors should be available round the clock.

A place of rest, a place for the aged, a place for substance abuse rehabilitation, a hotel, etc. that may be termed as ‘hospital / nursing home’ does not fall under the health insurance definition of hospital / nursing home

Waiting period

It is the period for which you must wait before filing a claim for that said medical condition. For example, if you have diabetes at the time of buying the medical insurance policy, it comes under the category of pre-existing diseases, and you may have to wait 2,3,4 years before you can claim your expenses pertaining to diabetes. The number of years you have to wait for claiming on the specific ailment is called the waiting period, and it differs from one policy to another.

Endorsement

Endorsement is a process by which you can make changes in your insurance policy document. This is the document you receive after completing the payment to buy the policy. If you want to change a detail mentioned in the policy document, for example, a spelling mistake, you can get it done via an Endorsement process.

In some cases, it is also allowed to make changes in the existing cover via this process. For example, if you want to modify your cover or change address, you can do so using the Endorsement process

Ayush/ Alternative Treatment

Alternative treatments like Ayurveda, Unani, Homeopathy, Naturopathy etc. come under AYUSH. Many health care policies provide a cover for AYUSH treatments as well, for individuals who are not keen on the regular allopathic treatment.

Cashless claim

Cashless claim means that for hospitalization/treatment taken at the insurance provider's network hospital, you do not pay for the expenses. Instead, your insurer is informed about the treatment at the hospital when you get admitted or before.

The insurer approves the claim and then settles the claim directly with the hospital. You only have to pay for the expenses that are non-payable or are other than the approved claim amount.

Insurance

An insurance is a legal agreement between an insurer (insurance company) and an insured (individual), in which an insured receives financial protection from an insurer for the losses he may suffer under specific circumstances.

Under an insurance policy, the insured needs to pay regular amount of premiums to the insurer. The insurer pays a predetermined sum assured to the insured if an unfortunate event occurs, such as illness, death or damage to the insured or his property.

The literal meaning of insurance would be an assurance against unforeseen and unfortunate loss. This means, that if you encounter a less than normal event in your normal course of life, and happen to incur a financial loss because of it, you can be compensated.

Co-payment

Co-payment in health insurance refers to the percentage of the claim amount which the policyholder is required to pay from their end and the rest is borne by the insurance company in case of a health insurance claim.

There are many insurance companies offering health insurance plans with mandatory co-payment clauses, whereas others come with a voluntary co-payment option. The policy buyers can buy health insurance with voluntary co-pay and enjoy a reduced premium for that policy. There are plans available with no co-payment also.

Day care treatment

A day care procedure is the one that does not last more than 24 hours and is usually taken care of during 1 day without a need for an overnight stay at the hospital. A popular example of this is cataract surgery. Not all medical policies may cover all types of day care procedures; hence, we suggest you go through the list of procedures provided in the policy document.

Domiciliary treatment

Domiciliary Hospitalization means that the insured person is given standard medical care for their illness, disease or injury in their house when the insured person is confined to their house for prevailing or existing reasons. However, the circumstances under which our company provides for medical care and takes care of the insured sum are the following:

• The insured person cannot be transferred to a hospital due to their condition;
• The insured person has to be treated at home due to the non-availability of hospital beds in the medical institution or hospital.

Health Insurance

Health insurance is a protection cover that you buy for yourself and your family, to take care of your medical expenses. You pay an annual fee called a premium, to insure a fixed amount of money in case of any medical requirement in your family. This fixed amount of money that you can avail is called your medical cover/sum insured. Hypothetically, if you are paying ~Rs 12,000 per year to ensure a health cover of Rs 5 Lakh for your family of 3, then Rs 12,000 is the premium you are paying.

Common Exclusions of Health Insurance Policies

• All policies do not cover claims in the first 30 days of buying the policy, except for accidents.
• Most policies cover pre-existing diseases after a specific waiting period.
• Cosmetic procedures (plastic surgery, hormone replacement therapy, etc.)
• Dental treatment and eye surgery
• Self-inflicted injuries or suicide attempts
• Critical illness cover comes after a waiting period
• Injuries from adventure sports
• Injuries from war, terrorism or nuclear activity
• Sexually transmitted diseases like AIDS
• Non-medical expenses like service charges, toiletries, etc.
• Non-prescription drugs

The actual exclusions of your policy may vary depending on the insurer and health insurance terms and conditions. Make sure to read the fine print and know all the exclusions to avoid claims rejection during times of crisis.

Insurer

The insurer is the insurance company whose medical policy you have bought.

Insured

The person who is covered by a policy of insurance.

IRDA

It stands for Insurance Regulatory and Development Authority of India. It is the governing body for all insurance services in the country. The IRDAI comes up with the rules and regulations for providing insurance coverage.

Policy Document

A policy document is a very detailed document containing the definitions, details of coverage, exclusions, monetary caps/limits and other details related to the policy you are looking to buy. Going through the policy document, we suggest, is a must. This ensures that at the time of claim, you don’t get any surprises.

Pre-existing ailments

A pre-existing disease is an ailment/injury that you may have at the time of buying a health insurance policy, diagnosed by a doctor up to 48 months prior to your application of buying the policy. Most policies have a ‘waiting period’ (which varies) before they start covering such diseases. In fact, the types of diseases covered also vary from one policy to another.

Although the pre-existing ailments gets covered by the policy after a certain period, it is advisable to disclose any such existing ailment and ongoing medication, if any to the insurer. Non-disclosure may result in rejection of the claim

Pre-existing ailments

A pre-existing disease is an ailment/injury that you may have at the time of buying a health insurance policy, diagnosed by a doctor up to 48 months prior to your application of buying the policy. Most policies have a ‘waiting period’ (which varies) before they start covering such diseases. In fact, the types of diseases covered also vary from one policy to another.

Although the pre-existing ailments gets covered by the policy after a certain period, it is advisable to disclose any such existing ailment and ongoing medication, if any to the insurer. Non-disclosure may result in rejection of the claim

Sum insured

The sum insured or the health cover in a medical insurance policy is the benefit you get in return of the premium you pay. For example, if you pay a premium of Rs 10,000, you may insure yourself and your family against the medical expenses up to Rs 3 Lakh (hypothetical figures). The sum of Rs 3 Lakh is your sum insured or health cover. Once you exhaust this cover, you will have to pay for the rest of the expenses from your pocket.

Super top-up

A Super top-up is an additional cover you can buy for yourself or your family members on top of your existing health insurance plan. The price of the premium will vary based on the deductible chosen. If you feel that your company's health insurance coverage is not enough, you can buy a super top-up health plan. This way you can increase your coverage without having to pay as much as you would for a standard health plan.

Nominee

Nominee is the person whom the policyholder nominates for receiving the sum assured after his/her death. Nominee could be the wife, children or parents of the policyholder. The nominee needs to claim the insurance benefit after the demise of the policyholder.

Sub Limits

Some health insurance plans have specific limits set for specific expenses like room rent, ICU Charges, cost of surgery, etc. which is linked to the overall coverage or the sum insured of the policy. For example, the most common sub-limit is on room rent of 1% of the sum insured. So, if you have a health insurance plan of INR 10 lakhs, then you can get room rent limit upto 1% of INR 10 lakhs, i.e. INR 10,000 per night. Other associated costs would also be proportionately deducted at the time of claim payout. However, if you choose a room rent of more than INR 10,000 then the remaining part needs to be paid by you and the same would not be covered by your health insurance plan.

However, new-age health insurance plans do not have any room rent limit. In that case, as long as the total claim is less than the sum insured of the plan, the same would be approved irrespective of the room rent limit or the cost of surgery, etc.