Health Insurance Claim, Coverage and Benefits

Posted in: Insurance | on: August 10, 2020


Health problems, illness or deficiency in health will occur to any person regardless of gender, age or lifestyle. As the health issues cannot be predicted before, one of the methods to be financially prepared against health emergencies is by having health insurance.

Health Insurance safeguards every member of the family during emergencies. It is a contract made between the policyholder and the insurance company. Under this scheme, when one pays a premium annually, the company will pay them their medical expenses in the case of emergency.

Health insurance is an insurance cover which pays for medical, surgical, drug and dental expenses spent by the insured. The health insurance policy covers expenses incurred for the treatment or provides the amount directly to the care provider. The benefits received under this scheme are non-taxable. However, there are some exceptions for S Corporation employees.

Health Insurance Coverage:

The benefits provided under this scheme includes hospitalization charges, expenses for diagnostic reports, medicines, day care expenses, pre and post hospitalization charges, accidental coverage, daily expenses for travel, food, accommodation etc.

What are the major benefits of Health Insurance Policy?

Cashless medical treatment:

With the help of health insurance policy, one can avail cashless medicare facility. It will offer them a lot of benefits during an unexpected condition.

It also offers claims for alternate remedies including the treatments under ayurveda, homeopathy, etc.

Tax benefits:

Health insurance offers tax benefits. Premium amount includes tax exemptions under Section 80D of the Income Tax Act of 1961. For parents whose age is more than 60 years, tax benefit of up to Rs. 50,000/- is allowed. The premium paid for the policyholder, spouse and children will be deducted up to Rs. 25,000/-. Hence, the total deduction of up to Rs. 75,000/- will be availed annually.

Coverage for critical illness:

This policy offers expenses for the critical health problems like kidney failure, heart problems, bone marrow transplant, AIDS, stroke, cancer, loss of limbs etc. One can avail the benefits for diagnosis of the critical illness from the predetermined list.

Extra expenses:

It covers extra expenses including the daily expenses incurred on food, travel, room rent etc. Generally, daily cash up to Rs. 2000/- will be availed. But in the case of accidental care and ICU care, these costs may vary.

Expenses for organ transplant:

The insurance company will take care of the costs of organ transplantation and the surgery expenses regarding organ donation.

No Claim Bonus (NCB):

No Claim Bonus is a benefit availed from the insurance company for every claimless year. NCB will be added as a discount amount on the payable premium at the policy renewal time or when the policyholder intends to increase the total assured amount. One must check for no claim benefit at the time of renewal.

Health check-ups:

Insurance company offers free health checkups. One can get frequent free checkups under this scheme. Based on the type of policy and insurance company, one can qualify for master health check-up plans.

Restoration benefits:

In the schemes like family floater plans, restoration benefit will be covered. If the amount is completely used up or exhausted, then the amount will be restored by the company.

Renewable policy:

It offers lifetime time renewability, which means the policyholder have to constantly renew it until their lifetime.

What are the types of Health Insurance Plans?

Some of the types of health insurance plans are Individual Health Insurance Plan, Family floater Health Insurance Plan, Group Health Cover, Maternity Insurance, Senior Citizen Health Insurance, Hospital Daily Cash, Critical Illness Health Cover, Super Top-Up Policy etc.

Individual plan:

Self health insurance plan includes the medical coverage of an individual. It covers surgical and treatment costs. The premium will be based on the medical history and the age of the policyholder.

Senior Citizen Health Insurance Plan:

This plan benefits the people above 60 years of age or the elder people of the family. According to the IRDAI rules, insurers have to provide cover up to the age of 65 years.

Maternity Insurance Plan:

It covers all the expenses including pre and post-natal care, delivery expenses as well as the ambulance services.

Critical Illness Plan:

It is a benefit-based plan for treating certain life-threatening diseases and it includes coverage from the diagnosis costs to the treatment costs.

Health Insurance For Parents:

As it is the duty of the children to take care of their parents, this plan is suitable for the individuals having sick parents. This plan covers both pre and post hospitalization charges, ambulance charges and treatment costs for pre-existing diseases.

Family Floater Plan:

This plan covers the whole family under one umbrella plan. It includes pre and post hospitalization costs. It provides benefits for self, spouse, children, and parents in the family. The premium amount will be based on the elder people in the family.

Group Health Insurance Plans:

It is offered for the employees by their employer. The premium in this plan is lower when compared to the individual health insurance policy. As it is a standardized policy, it provides equal benefits to all their employees.

Super Top-Up Plan:

Super top-up plans offer extra benefit over the policy increase against the amount of sum insured. This policy can be used only after the sum insured in a regular policy.

How to claim Health Insurance?

One can claim health insurance through cashless claim and reimbursement claim.

Cashless claim:

One has to follow the steps given below for cashless claim:

Step 1: Check whether the treatment is covered according to the terms and conditions of the health insurance policy. Also check if the hospital comes under the list of insurance company.

Step 2: Inform the insurance company about the claim on the insurance policy. During the admission session at the hospital, one has to fill and submit the Pre-Authorization Form at TPA (Third Party Administration) counter. The respective authority will hand over the form to the insurer for claim approval.Step 3:One has to submit all the required documents including Cashless Health Card, KYC documents etc. at the TPA counter for approval and verification process.

Step 4: If the insurer guarantees the cashless approval for the claim, then the original documents related to the hospitalization will be retained by the insurer. Therefore, one has to keep a copy for themselves.

Step 5: To claim pre and post hospitalization coverage, one has to retain the bills and all related prescriptions, bills and medical reports of the treatment.

Reimbursement Claims:

For reimbursement claims, one should follow the below steps:

Step 1: For claiming benefits under the reimbursement plan, one has to contact the company and submit the duly filled reimbursement claim form to the insurer within one month from the date of discharge from the hospital.

Step 2: Attach all the original copies of the medical reports, prescriptions, medicine bills and treatment bills with the claim form. The hospital bill must include the registration number of the hospital. The reports bearing the patient's name and date must be attached along with the prognosis prescription of the doctor.

Step 3: Once you have discharged from the hospital, the hospital will provide a Discharge Summary/ Card which assures your fitness to get discharged. This discharge card is to be submitted to the insurer.

Step 4: The follow-up prescription which assures fitness after hospitalization should also be submitted. For post-hospitalization expenses, all the bills have to be submitted within the certain time period as per the terms and conditions specified.

Step 5: One should keep the copies of all submitted documents for future reference. The claim will be settled within 2 to 3 weeks after the claim is registered.

As health is an important thing, one must take care of their health first. For that, one should take health insurance policy for themselves and also for their family so that they need not have to worry about the unexpected health expenses.


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