Standardization of Health Insurance Policy

We all know how important a health insurance policy is. But in some cases, policyholder claims are denied, and this has led to standardization in the health insurance policy in India. So, the new rules are developed to provide people with successful claims so that they get the money when needed.

Some guidelines have been introduced by Insurance Regulatory development authority of India to standardize the sector to help the policyholders and improve healthcare in India.

Any Illness

Any illness here refers to a prolonged period of illness including a relapse under 45 days from the date of consultation with the hospital.

Cashless Facility

This service is provided by the insurer where all the payments of the treatment taken by the insurer and are cleared to the network provider by the insurer until the preauthorization is approved.

Co payment

It is a facility of sharing a cost by the insurer and insured where they bear some percentage of the claim amount. But it does not reduce the sum that was insured.

Daycare Center

Daycare center means any institution established or any hospital with medical facilities that provide day care treatment of illness and complies to certain criterion as listed-: 

• It must have qualified nursing staff
• It must have a qualified practitioner
• It has an operation theatre with all the necessary equipment where the medical procedure can be carried out
• It has records of patients and which are accessible to the insurance company

Dental Treatment

There is also a standard for dental treatments, which means the treatment of teeth including all the activities like filing, cleaning, and surgeries.

Emergency Care

This involves treatment for some particular illnesses which occur suddenly require a doctor to treat to prevent any unwanted situation.

Grace Period

It involves a certain period which follows the premium date when the payment can be renewed or made without loss of any benefits.

Hospital

Hospital is a unit for the treatment of injuries for the people and for the daycare treatment is registered with the authorities. It should comply with the following criterion:

• It has nursing staff who works round the clock.
• It has bed facility for the patients with a minimum of 10 beds.
• It has a well-qualified medical practitioner.
• It has an operation theatre with all the necessary equipment and facilities.
• It has records of patients and which are accessible to the insurance company

Working of Mediclaim Policy

Cashless Policy

It is a policy where the insured is treated in the network hospital where the insurer has to pay the entire claim to the hospital. The patient doesn't pay any amount and all the things are managed by the insurance company

Hospital Room Charges

All the charges of room whether general ward or intensive care unit are taken care of in the network hospital with a cashless transaction.

Things that are not covered in the mediclaim policy

• It will not cover pre-existing disease
• Birth control and hormonal treatment
• Expenses incurred in dental surgeries

Health Insurance Claim Process

Health Insurance claims help the policyholders to claim their money in case of any unforeseen accident. But it involves certain procedures. They are:

• Cashless claim process
• Reimbursement process

Cashless Claim Process

This is a process in which all the claim is paid by the insurer and it helps to remove the insured from all the payment problems. Once the patient has discharged the hospital forwards the bill to the insurance company and then the latter has to pay for it.

Reimbursement Claim Process

In this, the insured when admitted to the hospital has to pay for the treatment and then after that, he can claim for the amount from the insurer. So, the hospital takes the payment from the insured and not from the insurance company. So, the policy holder makes the reimbursement claim.

So, these guidelines set that help to reduce the frauds and increase satisfaction among the policyholders and standardize health insurance in India. Through this clause, one can easily understand the different procedures in the policy and buy suitable policy according to their needs. There are many health insurance companies in India from where one can take suitable health insurance policy and get benefit from it.