Health insurance is about providing security as well as services including cashless payments for medical care needed in times of illness and disability. The purchase of health insurance reduces the risks and unpredictability inherent in a consumer’s health care expenses. The consumer pays premium for health insurance policy and is subsequently reimbursed for his or her medical expenses as per policy terms and conditions.

Health has always been of paramount importance for everyone. Everyone needs to be physically and mentally fit. Health systems that need to serve all must have a critical component of health financing and in this area health insurance plays a very crucial role. Health insurance can help in financing the treatment costs of those who fall ill. Health insurance also becomes important because of unpredictable nature of spending on healthcare.

Broadly speaking, there are 3 categories of health insurance products:

Hospitalization/indemnity Benefits:

These products pay actual medical expenses incurred due to hospitalization. These policies are issued for sum insured of RS 50000 to RS 100 lacs. These policies can be issued for 1 to 3 years but it is alway advisable to take policy for one year so that one may revise the sum insured at the time of renewal. Besides hospitalization expenses, expenses for before and after hospitalization for specified periods are also covered under the policy. Various add on features like free health checkup, cumulative bonus, hospital daily cash, higher benefits for ICU admissions, restoration of sum insured after the payment of claim, are also available.

Such policies may be available on individual sum insured basis, or on a family floater basis where the sum insured is shared across the family members.

Fixed benefit-also called Hospital cash:

These products pay a fixed sum per day for the period of hospitalization. The insured gets a fixed sum irrespective of the amount spent for the named procedure. For processing of claims, only proof of hospitalization and coverage of ailment are required.

Critical Illness benefit:

Policy provides a fixed lump sum amount to the insures in case of diagnosis of a specified illness or on undergoing a specified procedure. Once this lump sum is paid, the plan ceases to remain in force. This policy is available as a standalone policy or as an add on cover to few health insurance policies or as an add on cover few life insurance policies.

Health insurance policies usually do not include expenses incurred while outside India. For outside India, another product.

Travel insurance or overseas insurance:

Health insurance policies usually do not include expenses incurred while outside India. For outside India, another product Travel insurance is to be purchased. Such policies are meant for accident and sickness benefits. Most products are available in the form of package of covers the package contain the covers like Accidental death/disability, medical expenses due to sickness/accident, loss of passport, loss of checked in baggage, personal/third party liability for property/personal damages, delay in arrival of checked baggage, trip cancellation, hijack etc.

Health insurance policy covers medical expenses in the event of hospitalization because of Illness or accidental bodily injury sustained or contracted during the policy period.

All expenses incurred as an inpatient for accommodation, boarding expenses including patient diet as provided by the hospital/nursing home, nursing care, the attention of medically qualified staff, undergoing medically necessary procedures, and medical consumables are payable under the policy.

Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions are directly made to the network provider by the insurer to the extent pre-authorization is approved. This facility is offered only by network providers hospitals, the list of which is made available to the client along with the policy document.

Pre-hospitalization Medical Expenses means medical expenses incurred during predefined number of days preceding the hospitalization of the Insured person, provided that such medical expenses are incurred for the same condition for which the insured person’s hospitalization was required and the In-patient hospitalization claim for such hospitalization is admissible by the Insurance company.

Post-hospitalization Medical Expenses means medical expenses incurred during predefined number of days immediately after the insured person is discharged from the hospital provided that such medical expenses are for the same condition for which the insured person’s hospitalization was required, and the inpatient hospitalization claim for such hospitalization is admissible by the insurance company.

Not so any expenses that are not payable under the policy will not be considered during hospitalization and same will have to be borne by the patient.

Telephone charges, barber or beauty services, foods charges (other than patient’s diet provided by the hospital), baby foods, cosmestic, toiletries, tissue paper and similar expensed are not payable.

You can claim deduction toward the premium paid for health insurance policy under Section 80DYou will save tax under Section 80D of the Income tax Act. Tax benefits are subject to change in the tax laws, please consult our tax advisor for detail. For the Year 2018-19, the following limits are applicable.

Deductions under section 80D
Situations based on age Eligible deduction limits (up to Rs.) Total eligible deduction limit under section 80D (up to Rs.) (including Rs. 5,000 on preventive health checkups)
Medical Insurance Premium paid in respect of
Medical Insurance Premium paid in respect of Parents (whether dependent or not)
No one has attained age of 60 Years 25,000 25,000 50000
You and your family is less than 60 years & Parents are above 60 years of age 25,000 30,000 55000
You and your parents have attained the age of 60 years and above 30,000 30,000 60000

Cumulative bonus means any increase or addition in the Sum Insured granted by the insurer in lieu of no claim during the preceding year without an associated increase in premium. If the claim is made in any year, the cumulative bonus accrued may be reduced at the same rate at which it is accrued.

Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is taken while confined at home in situations where he/she is not in a condition to be moved to a hospital, or the patient takes treatment at home because of non-availability of room in a Hospital.

As per IRDA guidelines, a 30-day grace period is allowed for renewal of Individual Health policies, all continuity benefits are maintained if the policy is renewed within 30 day from expiry of the earlier insurance. Claim, if any, during the break period will not be considered.

As per IRDAI guidelines the insurer shall have to provide for a mechanism to condone a delay in renewal up to 30 days from the due date of renewal without deeming such condonation as a break in policy. However, coverage need not be available for such period.

Yes. When you get a new policy, generally, there will be 30 days waiting period starting from the policy inception date, during which period any hospitalization charges will not be payable by the insurance companies. However, this is not applicable to any emergency hospitalization occurring due to an accident.

This waiting period will not be applicable for subsequent policies under renewal.

In addition to the above there is a waiting period of 4 yeras for pre -existing diseases and two year for sum of the ailments. List of ailments not covered for first two years varies company to company. Some examples of the ailment not covered during first two years are- Cataracts, Hernia of all types, Fistulae, Fissure in ano, Hydrocele, Fibromyoma, Fibromyoma, Hysterectomy, Surgery for any skin ailment, Surgery on all internal or external tumours, Stones in the urinary and biliary systems, Tumour or growth.

Pre-Existing Disease means any condition, ailment or injury or related condition(s) for which there were signs or symptoms, and / or were diagnosed, and / or for which medical advice / treatment was received within 48 months prior to the first policy issued by the insurer and renewed continuously thereafter.

Depending on the product the waiting period of two year apply for certain diseases like, Cataract, Benign prostatic Hypertrophy, Hysterectomy for menorrhagia or Fibromyoma, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis, Gall Bladder stone etc.

There is no limit on number of claims to be lodged under health insurance. However, the sum insured is the maximum limit under the policy.

Family Floater is one single policy that takes care of the hospitalization expenses of entire family. The policy has one single sum insured, which can be utilized by any/all insured persons in any proportion or amount subject to maximum of overall limit of the policy sum insured. Often Family floater plans are better than individual policies.

Insurance companies pay the reasonable cost incurred on an ambulance offered by a healthcare or ambulance service provider for transferring the patient to the nearest Hospital with adequate emergency facilities for the provision of health services following an emergency. Insurance companies also reimburse the expenses incurred on an ambulance offered by a healthcare or ambulance service provider for transferring the patient from the Hospital where you were admitted initially to another hospital with higher medical facilities.

Some health insurance policies pay for specified expenses towards general health checkup once in a few years. Normally this is available once in four years.

There is no such requirement as per policy Terms and conditions.

Any one illness means continuous period of illness and includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment was taken.

An accident means sudden, unforeseen and involuntary event caused by external, visible and violent means.

Day care treatment means medical treatment, and/or surgical procedure which is undertaken under General or Local Anesthesia in a hospital/day care center in less than 24 hrs. because of technological advancement, and which would have otherwise required hospitalization of more than24hours.Treatment normally taken on an out-patient basis is not included in the scope of this definition. (Insurers may, in addition, restrict coverage to a specified list.

Co-payment means a cost sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claims amount. A co-payment does not reduce the Sum Insured.

A specific amount that your health insurance company may require that you pay out-of-pocket each year before your health insurance plan begins to make payments for claims. Not all health insurance plans require a deductible. A deductible does not reduce the Sum Insured. Is there any criterion for selecting a hospital at the time of admission? As per policy terms & conditions for availing cashless facility one can select any hospital from the list in network hospitals. If you want to selection-network, you will have to make the payment of the hospital from your own pocket and file the paper to TPA for re-imbursement claim.

ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards ICU expenses which shall include the expenses for ICU bed, general medical support services provided to any ICU patient including monitoring devices, critical care nursing and intensivist charges.

Newborn baby means baby born during the Policy Period and is aged up to 90 days.

OPD treatment means the one in which the Insured visits a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient. OPD treatment is not covered under the Mediclaim policy.

Room Rent means the amount charged by a Hospital towards Room and Boarding expenses and shall include the associated medical expenses.

Network Provider means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.

Unproven/Experimental treatment means the treatment including drug experimental therapy which is not based on established medical practice in India like Reiki, Acupressure, Spinal Decompression, Aqua massage/Hydrotherapy, Colour Therapy etc.

Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or day care center by a medical practitioner.

AYUSH treatment means medical and/ hospitalization treatment given under non allopathic system like “Ayurveda, Yoga and naturopathy, Unani, Siddha and Homeopathy systems.”Insurers may provide coverage to non-allopathic treatments depending upon the product features provided the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India/National Accreditation Board on Health or any other suitable institutions.

The essential Health benefit is:

  1. Coverage of medical expenses during hospitalizations, Pre-hospitalizing Pre- Hospitalization
  2. Cashless facility
  3. Ambulance facility
  4. Domically hospitalization
  5. Day care
  6. Treatment
  7. Free Health checkup
  8. Cumulative Bonus
  9. Guaranteed renewability

There are six standalone Health Insurance Companies transacting only health insurance business. These companies also offer Personal Accident, Domestic travel and overseas travel policies.

It refers to the failure of refusal to disclose or reveal part or full information that is required to be disclosed e.g. non-disclosure of past medical history of hypertension.

In the event of insured hospitalised for a disease/ illness/ injury for a continuous period exceeding 10 days some insurance companies pay benefit of certain amount per policy year. This benefit will be triggered provided that the hospitalization claim is accepted under In Patient Hospitalisation Treatment Cover.

It refers to a false statement of fact made by one party to another party which has the effect of inducing that party into the contract e.g. Wrong date of birth provided if falling outside age criterion of the product.

The Insured gets a fixed sum for each day of hospitalization irrespective of the amount spent by him for the named procedure. The package charges payable for each of these procedures is generally based on a study of the reasonable cost that would be needed for treatment of the condition. In this product, commonly occurring procedures are listed under each system such as ENT, Ophthalmology, Obstetrics and Gynecology, etc. and the maximum pay out of each of these is spelt out in the policy.

The Public Sector Insurers viz National Insurance Co Ltd., New India Assurance Company Ltd, Oriental Insurance Co Ltd & United India Insurance Co Ltd have negotiated special package rates from many hospitals across India for a good number of procedures commonly undergone. Cashless facility for those procedures is available only in the GIPSA Network Hospitals. Claim for treatment taken elsewhere will have to be submitted for reimbursement.

Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved.

As an inpatient for covered event minimum 24 hours is required as per policy term and condition. However, for medical treatment, and/or surgical procedure which is undertaken under General or Local Anaesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and which would have otherwise required hospitalization of more than 24 hours, claims is covered .

Congenital Anomaly means a condition which is present since birth, and which is abnormal with reference to form, structure or position. Congenital anomalies are of two types:

a) Internal Congenital Anomaly

Congenital anomaly which is not in the visible and accessible parts of the body.

b) External Congenital Anomaly

Congenital anomaly which is in the visible and accessible parts of the body

The cancellation clause is also standardized by regulatory provisions and an insurance company may at any time cancel the policy only on grounds of misrepresentation, fraud, and non-disclosure of material fact or non-cooperation by the insured. A minimum of fifteen days’ notice in writing by registered A/D to the insured at his last known address is required, in which case the company shall return to the insured a proportion of the last premium corresponding to the unexpired period of insurance if no claim has been paid under the policy.

Yes, most of insurance company allowed 10 % family discount if 2 or more than 2 of the dependent family members are covered under a single policy. The family discount will be offered for both new policies as well as for renewal policies.

One cannot enhance the sum insured during the currency policy. However, it is allowed at the time of the renewal policy. The acceptance of enhancement of sum insured would be at the discretion of the company, based on the health condition of the insured members& claim history of the policy.

All waiting period as defined in the policy shall apply for this enhanced sum insured limit from the effective date of enhancement of such sum insured considering such policy period as the first policy with the company.

Due to life style diseases& accident, escalating medical expenses and absence of any form of public health security net episodes of hospitalization are increasing day by day. Hence more and more people are demanding health insurance people.

Health insurance premium depend on age of persons to be insured and sum insured opted Age is a major factor that determines the premium, the older you are, the premium cost will be higher because you are more prone to illnesses. Previous medical history is another major factor that determines the premium. If no prior medical history exists, premium will automatically be lower. Claim free years can also be a factor in determining the cost of the premium as it might benefit you with certain percentage of discount. This will automatically help you reduce your premium at the time of renewal.

Maternity expenses mean;

a)Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization);

b)Expenses towards lawful medical termination of pregnancy during the policy period.

There are certain generally excluded items such as consumables, non-medical items including toiletries, cosmetics, personal comfort or convenience items, apart from certain elements of room charges, administrative charges, and cost of external durable. Devices and others that insurers may offer cover either as part of a basic cover or as an add-on, optional or otherwise under a health insurance policy. As per IRDA regulation it is necessary to specify upfront what is being included and what is excluded by mentioning the same in the insurance policy. Where the insurer has a list of expenses not covered under the policy, the same has to be mentioned in the policy and the detailed list needs to be put up on the website of the insurer to enable the policyholder to refer to the details as and when required.

Cashless claim may be rejected for variety of reasons. Lack of documents or hospital not falling in network, incomplete patient information, information sent insufficient, aliment not covered under the policy, medical record/history not available, services excluded or not covered, waiting period are the primary reasons for denial of cashless claim. In such cases, the hospital expenses are be borne by the policy holder & then file a claim with Insurance company/TPA for reimbursement of expenses.

i. A health insurance policy shall ordinarily be renewable except on grounds of fraud, moral hazard or misrepresentation or non-cooperation by the insured.

ii. The renewal o f a health insurance policy sought by the insured shall not be denied arbitrarily. I denied, the insurer shall provide the policyholder with cogent reasons for such denial of renewal.

iii. A insurer shall not deny the renewal o f a health insurance policy on the ground that the insured had made a claim or claims in the previous or earlier years, except for benefit based policies where the policy terminates following payment of the benefit covered under the policy like critical illness policy following payment of the critical illness benefit, the policy terminates.

In case of products with term of one year and less, if such cost is to be incurred by the insured, 50% of such cost shall be borne by the insurer once the proposal is accepted, except in travel insurance policies where such costs need not be reimbursed.

There is no such loading, however at time of renewal the premium can increase after certain age as the insurance co. has different premium slabs for different age groups.

Dental treatment means a treatment related to teeth or structures supporting teeth including examinations, fillings (where appropriate), crowns, extractions and surgery.

Dental treatment or surgery of any kind unless as a result of accidental bodily injury to natural teeth and also requiring hospitalization is not covered in health insurance policies.


Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological functions and requires medical treatment.

(a) Acute condition:

Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.

(b) Chronic condition

A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:

1. It needs on going or long-term monitoring through consultations, examinations, check-ups, and /or tests

2. It needs on going or long-term control or relief of symptoms

3. It requires rehabilitation for the patient or for the patient to be specially trained to cope with it

4. It continues indefinitely

5. It recurs or is likely to recur

Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent, visible and evident means which is verified and certified by a Medical Practitioner

Inpatient Care (not applicable for Overseas Travel Insurance):

Inpatient care means treatment for which the insured person must stay in a hospital for more than 24 hours for a covered event.

Yes, NRI’s can take Health insurance in India. They can travel to India for treatment and can claim it. However, they will have to show their residence proof, ITR and a few other documents.

In a critical illness policy, you are covered for certain mentioned critical illnesses only. Some of coverage’s are Kidney disease, brain tumours, and major organ transplant and many more depending on the companies.

If you have normal health insurance you will get covered for critical illness but in critical illness you won’t get coverage for normal disease like malaria, typhoid.

While most critical illness policies provide for a lump sum payment n diagnosis of illness, there are a few policies which provide hospitalisation expenses cover only in the form of reimbursement of expenses.

Ans Some of the insurance companies like to reimburse out -of pocket expenses like transportation, attendant cost & other daily expensed with our (Daily Allowance)- a lump sum per day each day of hospitalization in the form of non-medical expenses.

Non-Life and Standalone Health insurance companies may offer individual health products with a minimum tenure of one year and a maximum tenure of three years, provided that the premium shall remain unchanged for the tenure.

Insurance company also provide long term discount ranging from 2.5 % to maximum 10%.

Third Party Administrator mean any person who is registered under the IRDA (Third Party Administrator _ Health Services) Regulation, 2016 notified by the Authority, and is engaged, for a fee or remuneration by an insurance company for the purposes of providing Health services.

The main functions of TPA are:

  1. Issuing health I-card to the policy holder to validate their identity at the time of claim.
  2. Servicing of claim under health insurance policy by way of pre-authorization of cashless treatment while admitted in network hospital.
  3. Settlement of claim other than cashless treatment after being discharged from non-network hospital.
  4. Call canter service.
  5. Customer service support.

If individual health insurance policy holder travels abroad during the currency of the policy and Oversees Mediclaim Policy(OMP) is also taken from the same insurance company, the individual health policy may be extended for the period equivalent to OMP policy subject to submission of declaration of his travel abroad by policy holder.

Yes, dependent member can be added during the currency of the policy by way of endorsement or at the time renewal. Pre-existing disease, two-year exclusion waiting period and other exclusions for added member will be applicable considering such policy year as first year of the policy.

There could be a chance that the Insurance Company has still not forwarded your details to TPA. Also there is a possibility that your card has been dispatched and you have not received the same. You can call call center of insurance co. /TPA and they will guide you accordingly. Alternatively, you can log on to the website of TPA and enter your policy number to get your card status.

You may send your ID card back to TPA, mentioning the mistakes for example. name, age, gender, and photo etc. along with the rectification required. The corrected card will be dispatched to you within 7 days without any additional cost. You can also report the mistakes in the card by calling center of TPA and they will guide you.

Under the planned hospitalization program, you need to inform the insurance company or the Third-Party Administrator of the patient’s admission date in the hospital along with your Health Id card and policy number at least 4 to 5 days in advance.

  1. You can get the pre-authorization for cashless claims services and the intimation form to be sent to the third-party administrator from the admission counter of the hospitals You must fill up the form with due care as incorrect information may lead to rejection of previous authorization.

  2. The doctor attending the patient must fill in the medical condition of the patient or requirement of any surgical procedure. Make sure to brief the doctor correctly about the medical history of the patient else, a risk rejection of pre-authorization from the insurance provider exists.

  3. Subsequently, the hospital authorities send the filled-up form to the respective insurance company for granting the amount of pre-authorization involved in hospitalization.

  4. Next, the insurance provider scrutinizes relevant details like policy number, waiting period, sum assured, pre-existing diseases, etc. If satisfied they will send the authorization amount directly to the hospital.

    The insurance company will issue a pre-authorization letter or guarantee of payment to the nursing home or hospital stating that the sum guaranteed as payable concerning the ailment for which the person seeks admission as a patient.

  5. Third party administrator may deny the pre-authorization if it is not satisfied with the documentation

    It becomes essential to relentlessly pursue authorization letter because unless provided the hospital; will not treat it as a cashless claim.

  6. In case the Third-Party Administrator does not issue the letter, the patient has to pay from his pocket and then lodge a claim for reimbursement.

  7. In case of planned hospitalization, it is easy to get pre-authorization as the policyholder has ample time to follow up the service provider. However, things get tough in case of emergency hospitalization. Time is significant, as the hospital will not start treatment if it does not receive authorization or cash from the insured.

  8. Third Party Administrators grant authorization for only the amount agreed on the policy. If the cost of treatment exceeds the agreed amount, the patient must pay the excess fee and then place a claim for reimbursement if permitted in the policy.

Following documents are required for processing claims on reimbursement basis:

  1. Claim form duly filled & signed by the insured.

  2. Copy of member ID card.

  3. Copy of policy.

  4. Discharge summary / Discharge card (Original, Photocopy for pre/post hospitalization claim)

  5. Hospital bills (Original). For all consolidated amounts, the detailed breakup of the billed amount is required from the hospital.

  6. For medicines purchased from outside, the original bills should be accompanied by a prescription from the doctor.

  7. All investigation reports

  8. In case of hospitalization due to accident, medico legal certificate (MLC) from hospital.

  9. All previous treatment papers related to Ailment.

  10. Cancelled Cheque (with pre- printed name) / Copy of passbook of the proposer for electronic fund transfer Or completely filled NEFT form stating Branch MICR Code, Branch IFSC Code, Account type, Complete Account Number duly signed by insured and Bank authority and sealed by the bank (All Fields in the form are mandatory to process). {Not required if already provided}

  11. Registration Certificate of the hospital or a certificate from the hospital giving infrastructure details e.g. Number of Beds, Availability of Doctor’s & Nurse’s round the clock, Operation theatre etc.

The claim documents can be submitted to the concerned Insurance company/TPA.

One can approach the customer services department of TPA. If not satisfied with the resolution he may contact the respective insurance company. If still not satisfied you can approach us for further course of action.

Along with your member ID card, you will get a kit comprising of a Guide Book and List of Network Hospitals. You can also download the list from the website insurance co. /TPA".

One may immediately call TPA call center, giving details of such hospitals/medical providers. TPA will immediately contact the concerned medical provider and address the issue. However, the treatment should not be denied in any circumstances by the hospital.

You may write/email to TPA giving details of your grievance. Grievance department of TPA will address the issue within 72 hours.

Customer can also lodge a grievance at IRDA Integrated Grievance Management System or insurance company’s website/call centre. Policy holders can approach Ombudsman or Consumer Courts for unresolved disputes which are not addressed through grievance resolution channels.

Yes it is 48 hours from the date of admission in case of planned hospitalization and 6 hours in case of emergency.

Policy holder who desires for portability of his policy to others company has to port the entire policy at least 45 day before but non earlier than 60 day from the renewal date of his policy.

A health identity card is given to the policy holder by the TPA as proof of identification of insured person and to avail cashless facility in the network hospital. The health card will consist of a unique identification no. policy no., policy period and name and age of the policy holder one side. On the other side card are given instruction for cashless facility and toll-free no. of TPA.

This card is not a credit /debit card rather it is evidence/ proof of insurance and identification of the policy holder.

One should the check the following:

  1. Correctness of the name of the members covered

  2. Correctness of the sum Insured

  3. Room rent capping

  4. Loading and co-payment

  5. Exclusion

The Heath insurance policy is restricted to insured event and Mediclaim expenses incurred in India.

If any dispute or difference shall arise as to the quantum to be paid under the policy (liability being otherwise admitted) such difference shall be resolved through arbitration under the provisions of Arbitration and Conciliation Act, 1996.

Any person including a sole proprietor, micro entrepreneur, members covered in a group insurance policy who has a grievance against an insurer may by himself or through his legal heirs, nominee or assignee or employer as the case may be can approach an Insurance Ombudsman for redressal of any grievance arising out of an insurance policy by making a complaint in writing to the Insurance Ombudsman within whose territorial jurisdiction the branch or office of the insurer complained against or the residential address or place of residence of the complainant is located.

The Ombudsman will receive and consider complaints or disputes relating to:

  1. Delay in settlement of claims, beyond the time specified in the regulations, framed under the Insurance Regulatory and Development Authority of India Act, 1999;

  2. Any partial or total repudiation of claims by the life insurer, General insurer or the Health insurer;

  3. Disputes over premium paid or payable in terms of insurance policy; (d) Misrepresentation of policy terms and conditions at any time in the policy document or policy contract;

  4. Legal construction of insurance policies in so far as the dispute relates to claim;

  5. Policy servicing related grievances against insurers and their agents and intermediaries;

  6. Issuance of life insurance policy, general insurance policy including health insurance policy which is not in conformity with the proposal form submitted by the proposer;

  7. Non-issuance of insurance policy after receipt of premium in life insurance and general insurance including health insurance; and

  8. Any other matter resulting from the violation of provisions of the Insurance Act, 1938 or the regulations, circulars, guidelines or instructions issued by the IRDAI from time to time or the terms and conditions of the policy contract, in so far as they relate to issues mentioned at clauses (a) to (f) .

The complaint shall be made in writing on a plain, duly signed by the complainant and shall state clearly the name and address of the complainant, the name of the branch or office of the insurer against whom the complaint is made, the facts giving rise to the complaint, supported documents if any, the nature and extent of the loss caused to the complainant and the relief sought from the Insurance Ombudsman.

Yes. No complaint to the Insurance Ombudsman shall lie unless the complaint is made within one year

  1. From the date of receipt of the order of the insurer rejecting the representation.

  2. From the date of receipt of decision of the insurer which is not to the satisfaction of the complainant;

  3. After expiry of a period of one month from the date of sending the written representation to the insurer if the insurer named fails Furnish reply to the complainant.

No. Any complainant, whose complaint on the same subject matter is or was before a Court/Consumer Forum or an Arbitrator cannot approach an Insurance Ombudsman.

I. No complaint to the Insurance Ombudsman shall lie unless- the complainant makes a written representation to the insurer named in the complaint and

  1. Ether the insurer had rejected the complaint; or

  2. The complainant had not received any reply within a period of one month after the insurer received his representation; or

  3. The complainant is not satisfied with the reply given to him by the insurer;

II. No complaint before the Insurance Ombudsman can be maintainable on the same subject matter on which proceedings are pending before or disposed of by any court or consumer forum or arbitrator.

Not necessary as formal court procedures are not involved.

In case both parties agree for mediation, the Ombudsman gives his Recommendation within 1 month; otherwise, he passes an Award within 3 months from the date of receipt of all requirements from complainant.

No fees / charges are required to be paid.

In case a complainant is not satisfied with the Award of an insurance Ombudsman he can exercise his right to take recourse to the normal process of law against the insurance company. However, the award of Insurance Ombudsman shall be binding on the insurers.

The Insurer shall comply with the Award within 30 days from the date of receipt of the Award and intimate of its compliance to the Insurance Ombudsman.

Sub limits are expressed a fixed value for a disease /treatment or room rent or as a percentage of the total sum Insured.

There are two types of Sub limits, one hospital room rent and the other on Sum Insured on specific disease.

Under the room rent option, the rent per day, the type of room and all others hospital charges linked to the room are capped and any charges over and above the limited must be borne by the patient.

Under sub limit on specific treatment, there is a cap on the amount you can claims depending on your disease/treatment and the remaining has to be borne by the patient, Hence, Hence, a high Insurance covered does not assure 100% coverage.

Critical Illness

Critical illness insurance is a form of health insurance that provides a lump-sum payment should you become seriously ill. Under this policy guaranteed cash sum will be paid if the unexpected happens and you are diagnosed with a critical illness as per list mentioned in the policy.

These can differ from policy to policy, typical illnesses and diseases covered critical illness insurance may include.


Most of the critical illness policies provide for a lump sum payment upon diagnostic of illness, whereas others health policy provides hospitalization expensed covered only in the form of reimbursement of expenses. Critical illness policy is sold as a standalone policy or an add-on covered to the health Insurance policy or as an add-on cover in some life insurance policies.

Health Insurance will be a big help to your recovery, but only up to a point, your health insurance has maximum limits, that when reached, will means that further expensed falling under a certain category will no longer be payable. There are also expensed that are not covered by health insurance -for instance, your incidental expenses, your loss of income during your hospitalization and so on, also critical illness covered will help pay for your household duly need as well a spray off loan.

In critical illness insurance the benefit amount is payable once the disease is diagnosed meeting specific criteria. The critical illness insurance requires that the insured should survive or outlive the waiting period for the payout to be given. Be sides there is waiting period of 90 days for the policy to commence i.e. any claim for any critical illness diagnosed within first 90 days is not payable.

Yes, once the money is paid out to you, you can spend it however way you wish. The primary purpose is for you to spend it for recovery that will further prolong your life and improve the quality of life. However, you can also spend it to pay for your household’s needs (seeing that your illness may prevent you from continuing with employment), have your house equipped with medical facilities or even spend it on you dream trip.

Yes, you can get a joint critical illness cover so that if either of you get critically ill, you can have the benefits.

No, once the payout is made for one covered critical illness, the policy will be considered terminated and no other further payout will be made.

The Sum Insured ranges from 1 lac to 1 crore.

The Insured needs to submit the claim form, certificate from the specialist confirming occurrence of the critical illness along with the discharge card and investigation report. Additional documents may be called for if any further information is required.

Cost varies depending on age, medical condition, your immediate family medical history, the amount of coverage, the number of illnesses covered by the policy and the insurance company.

Yes, Critical illnesses that result from these are excluded:

  1. Any Critical illness for which care, treatment, or advice was recommended or which was first manifested or contracted before the proposal.

  2. Any critical illness diagnosed within the first 90 day.

  3. Death within 30 days following the diagnosis of the critical illness.

  4. Presence of HIV/AID infection.

  5. Illegal or criminal activities.

  6. Abuse of illegal drugs, alcohol and other addictive.

  7. Attempted suicide or self -inflicted injury

  8. War, riots and civil commotions

  9. Failure to follow reasonable medical advice.

We, Worldwide Insurance Brokers Ltd. at can help you find best critical illness insurance and others type of health Insurance coverage.

Top Up/ Super top up

Unlike normal hospitalization policy, top up plans come with a deductible or threshold limit. You must select the threshold limit at the time of purchasing the policy- this is the amount up to which you or your existing policy can pay the medial bills. As long as your present ailment is fully met by your existing policy and the hospital bill meets the policy claim amount (through either cashless to reimbursement method) there’s no worry. The top up plan does not come into the picture here.

Top up plans work when your hospital bills show expenditure in excess of the medial insurance claim estimates cleared (either by in -house arrangement or through a third-party administrator) by the insurance company. In such a case, you can very well file an additional claim on the top up policy on the same hospital bill for treatment undergone.

A top-up cover will pay you for your claim amount (bill for a single hospitalization). A super top-up palm, on the others hand considers the total of all the bill in any given year. It covers ‘multiple’ hospitalizations and looks at the aggregate claims. This means the plan puts together several cases of hospitalization to calculate the deductible limit (threshold limit).

  1. You have a health -insurance policy but the sum assured is not significant to covered huge hospitalization costs.

  2. You want to maximize the premium amount.

It is advised to take a top up policy if you have a reimbursement cover at least for threshold limit of the top up plan.

All the family member can be covered under single policy with sum insured and threshold level to be provided for all insured persons separately.

Single Sum Insured /threshold level for all family members covered under the policy is provided under family floater top up plan.

Pre-acceptance health checkup required in the following circumstance:

  1. Age of the person exceeding certain yeas some company required pre-checkup at the year 45 and others may require at the age 50/55/60

  2. Adverse medical claim history

  3. Person not coved under health insurance policy

  4. Opting high sum insured in relation to sum insured under the existing policy.

Claim under this policy shall be payable only if the aggregate of covered medical expenses in respect to hospitalization of insured person exceeds the deductible applicable on per policy year basis. There expenses are covered as in patient treatment, Pre and post hospitalization, day care treatment, domiciliary hospitalization, Organ donor, emergency ambulance.

  1. Any Disease contracted during the first 30 days of inception of policy, except injuries arising out of accidents.

  2. Pre-existing diseases will be covered after a waiting period 4 year.

  3. Waiting period of 2 year/3 year for certain specified illness/treatment.

  4. External Congenital disease

  5. Dental treatment.

  6. Expenses arising from HIV/AIDS related diseases

  7. Naturopathy.

  8. Circumcision unless required for the treatment of Illness or Accidental bodily injury, Cosmetic Surgery, Plastic surgery.

  9. Injury arising out of drug/alcohol abuse.

  10. Maternity Benefit.

  11. Hospitalization dud toward or an act of war or due to nuclear, chemical or biological weapon and radiation of any kind.

  12. Cost of spectacles/Contact lenses.

  13. Expenses irrebuttable to self-inflicted injury (resulting from suicide/attempted suicide).

The Authority, as part of its administration of health insurance Business notified IRDAI (Health Insurance) Regulations, 2016 (hereafter referred as health insurance regulation, 2016). In accordance to the provisions of regulation.

12 (i) titled” Entry and Exit age” all health insurance policies shall ordinarily provide for and entry age of at least Up to 65 years. There is also Health Insurance Product that offers Health Insurance coverage beyond age 65 years.

In accordance to the provisions of regulation, once a proposal is accepted in respect of health insurance Policy (except personal Accident and Travel Policies) and a policy is issued which is thereafter renewed periodically without any break, further renewal shall not be denied on grounds of the age of the insured. Thus, health insurance policies

Are lifelong renewable.

X Insurance company will settle the claim Rs. 2 lac and the remaining amount Rs. 3 lacs will be paid by Y Insurance.

Explained with example the difference between top-up and super top up cover.

Policies Top-Up Cover Super Top-Up covered
Mr. X has base health Insurance of 3 lac sum Insured
In the event of He buys a top-Up plan to Rs. 8 lacs with 3 lacs as the deductible. He buys a super top-up Rs. 8 lac with 3 lacs as the deductible.
1. Single claim of Rs. 10 lacs Health Insurance plan will pay 3 lacs. Top-up plan will pay the remaining of 7 lacs. Health Insurance plan will cover 3 lacs. Super Top-up plan will pay the remaining of 7 lacs.
2. Two claims of Rs. 2 lacs each Health Insurance will cover for the 2 lac for the first claim and 1 lac second claim. There will be no clam pay out from Top- Up plan as the individual amount of the claim does not exceed 3 lacs Health Insurance will cover for the Rs. 2 lac of first claim and Rs. 1 lakh of second claim. Super Top up will cover the remaining 1 lac.
3. Claim of 4 lacs and RS. 2 lacs Health Insurance will pay 3 lacs from first claim Top up plan will pay the remaining rs1 lakhs for the first claim. Second claim of 2 lacs is not payable as it does not exceed the deductible limit. Health Insurance will pay 3 lakhs from first claim. Super top up will cover the remaining Rs.1 lac from the first claim and Rs. 2 lac for the second claim.