What is Health Insurance?

A medical insurance policy, also called as health insurance, covers medical expenses for illnesses or injuries. It reimburses your bills or pays the medical care provider directly on your behalf. A comprehensive medical insurance covers the cost of hospitalisation, daycare procedures, medical care at home (domiciliary hospitalisation), ambulance charges, amongst others.

A Health insurance plan helps you stay covered against various diseases. Additionally, it helps you boost tax savings. Under section 80D of the Income Tax Act, 1961, you can claim tax benefits against your health insurance premium.

Cashless Transactions on Health expenses.

At the time of hospitalisation, you don’t have to worry about arranging cash to pay your hospital bill. Your health insurance company will settle it directly with the hospital if it is in their network.

Have the freedom to choose any hospital for your & your family’s treatment without worrying about your finances. Avail cashless hospitalisation benefits at Network Hospitals . You no longer have to wait for the reimbursement of the claimed hospitalization expenses . With cashless hospitalisation benefits from our insurers partners, you can fast-track your and your family’s recovery without any added stress from hospital bills.

What are the benefits of buying a health insurance policy through our Guidance?

A comprehensive health insurance plan in India comes with many advantages.

1. Covers complete OPD requirements:

cover the expenses of all your minor and severe health concerns, including teleconsultation with the doctor, pharmacy, and routine diagnostics on a cashless basis.

2. Covers pre and post hospitalisation expenses:

One of the key benefits of a health insurance policy is that it covers your medical expenses incurred just before and after hospitalisation.

3. Covers pre-existing diseases:

A health plan covers you for a pre-existing disease once you have completed the waiting period mentioned in the policy certificate.

4. Tax benefits on a health insurance plan:

Health insurance is a crucial investment. It provides you and your loved ones financial security in case of a medical emergency. Whether it be an emergency or a planned hospitalisation, a health insurance policy ensures complete coverage by helping you pay for medical expenses mentioned in the policy.

Apart from safeguarding your finances from rising medical expenses, you can also avail tax benefits on the premiums paid towards your health insurance under Section 80D of the Income Tax Act, subject to terms and conditions. This makes a health insurance plan a smart investment.

The quantum of tax deductions under your medical insurance plan is as below:

1. a) If you purchase health insurance coverage for your spouse, children and yourself, you can save up to ₹25,000 (if you are lesser than 60 years of age) or ₹50,000 (if you are more than 60 years of age) as tax deductions.

1. b) By including your parents (below 60 years of age) under your health insurance coverage, you can avail of additional tax deductions up to ₹25,000, to take your total tax savings up to ₹50,000

1. c) In case your parents are ageing 60 years or above, the total amount of tax savings may increase up to ₹75,000 to ₹1,00,000

1. d) You can also avail of a deduction of Rs. 5000 towards payment of preventive health check-up of your spouse, dependent children, parents and yourself

5. 24*7 Support & Discounts:

our health assistance team is available to answer your health-related queries on our dedicated helpline 9500060080, 24Hours*7Days.

That’s not all. We let you claim every benefits under the Policy through our Guidance. You also get to save upto 10% on your health insurance premium when you pay Health  Insurance premium  for long tenure of 2 Years & 3 Years tenure.

6. Teleconsultations:

Unlimited teleconsultations, available 24×7 with health care professionals for routine & emergency health concerns

We will arrange consultations and recommendations for emergency or everyday health issues by a qualified healthcare professional via phone, video call or other virtual means.

TYPES OF HEALTH INSURANCE

How to Choose the Best Health Insurance Plan ?

When choosing a health insurance plan, it’s important to consider the following factors:

 Coverage: Make sure the plan covers the medical treatments and procedures that you may need in the future.

 Network of hospitals: Check if the hospitals you prefer to visit are covered under the plan’s network.

 Premium: Compare the premium of different plans and choose one that fits your budget.

 Co-payments and deductibles: Check if the plan has co-payments and deductibles and if you are comfortable with them.

 Renewability: Check if the plan is renewable for life or if there’s a maximum age limit for renewals.

 Pre-existing conditions: Check if pre-existing conditions are covered under the plan and if there’s any waiting period for coverage.

 Claim settlement ratio: Check the claim settlement ratio of the insurance company before choosing a plan.

 Add-on covers: Check if the plan offers add-on covers such as personal accident cover, critical illness cover, etc.

 Family coverage: If you are looking for a family health insurance plan, check the plan’s coverage for children and the number of members it covers.

Documents Required to Buy Health Insurance Plans:

Following are some of the documents that you might be asked to furnish while buying health insurance plans

• Age Proof (preferrably PAN or Masked Aadhaar or Driving License or other proofs issued by Government authorities)
• Identity Proof (preferrably Masked Aadhaar or Driving License or other proofs issued by Government authorities)
• Address Proof (preferrably Masked Aadhaar or Driving License or other proofs issued by Government authorities)
• Medical Reports
• Passport sized photograph of Proposer and Members to be insured.
• Cancelled Cheque Leaf or Bank Pass book front page or Bank statement carrying Name of the Proposer as Bank account holder Name.
• Filled Proposal Form

Note: The list of documents required might vary from one health insurer to another.

How do I Buy Health insurance policy that i opt for?

• Discuss the policy benefits, coverage and premium details with our insurance experts
• Actively seek information on the charges and exclusions under the policy
• Fill the online Application form, stating your personal details and Health profile (hyperlink to the Form)
• Ensure that the information given in the form on our website is complete and accurate
• We will process your proposal. Based on the information provided, you may be required to undergo pre-policy medical examination at network diagnostic centers.
• Depending on evaluation by the insurance companies, if your proposal is accepted, then we will issue the policy subject to receipt of annual single premium as published on the prospectus.
• The Policy Schedule, Policy Wordings, Cashless Cards and Health Guide will be sent to your mailing address mentioned on the proposal form

When can I enhance my Sum Insured?

1. The Insured can apply for enhancement of Sum Insured at the time of renewal. You can apply for enhancement of Sum Insured by submitting a fresh proposal form to the Company.
2. The acceptance of enhancement of Sum Insured would be at the discretion of the Company, based on the health condition of the Insured(s) & claim history of the Policy.

iii. All waiting periods 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.

Possibility of Revision of Terms of the Policy including the Premium Rates

The insurance Company, with prior approval of lRDAl, may revise or modify the terms of the policy including the premium rates. The insured person shall be notified three months before the changes are effected.

Portability Conditions

The Insured beneficiary will have the option to port the policy to other insurers by applying to such insurer to port the entire policy along with all the members of the family, if any, at least 45 days before, but not earlier than 60 days

from the policy renewal date as per IRDAI guidelines related to portability. If such person is presently covered and has been continuously covered without any lapses under any health insurance policy with an Indian General/Health

insurer, the proposed Insured beneficiary will get the accrued continuity benefits in waiting periods as per IRDAI guidelines on portability.

Renewal of Policy

The policy shall ordinarily be renewable except on misrepresentation by the insured person, grounds of fraud, misrepresentation by the insured person.

1. The Company shall endeavour to give notice for renewal. However, the Company is not under obligation to give any notice for renewal.
2. Renewal shall not be denied on the ground that the insured person had made a claim or claims in the preceding policy years.

iii. Request for renewal along with requisite premium shall be received by the Company before the end of the policy period.

1. At the end of the policy period, the policy shall terminate and can be renewed within the Grace Period of 30 days to maintain continuity of benefits without break in policy. Coverage is not available during the grace period.
2. No loading shall apply on renewals based on individual claims experience

At Smart Insurance Solution, we try to ensure always that our customers have best Health insurance coverage with more and more benefits. The inclusions of the various products are # :

Inclusions in Health Insurance Claims#

• Hospitalization expenses
• Domestic Road / Emergency Air Ambulance
• Domiciliary Hospitalization
• Modern / Advanced Treatments
• Pre and post hospitalization Expenses
• Organ donor expenses
• Reinstatement or Restoration of Base Sum Insured
• Extra Sum Insured
• Accidental Disability / Death Cover
• Waiver of Premium
• Cumulative Bonus
• Call Option for Enhancement of Base Sum Insured
• Wellness Services
• Dental treatment when specially covered or opted
• Infertility, Sterility, Birth control when specially covered or opted
• Treatment outside India when specially covered or opted
• Alternative treatments ( AYUSH Benefit ) when specially covered or opted
• Maternity expenses when specially covered or opted
• Non-payable items as per Annexure when specially covered or opted

# Coverage varies from Products to Products. Explanations mentioned in “What’s Covered ?” are illustrative and will be subject to terms, conditions and exclusions of the Policy. Please refer to the Policy Document for more details

Exclusions in Health Insurance Claims#

At Smart Insurance Solution, we believe in transparency. To ensure that you do not face any unpleasant surprises while making a claim, do take a look at some of the major exclusions of the policy.

Health insurance Covers Everything But This^

Non-Medical Exclusions

1. Nuclear attack / War / or similar situations
2. Breach of Law with criminal Intent
3. Intentional self-injury or attempted suicide
4. Dangerous & hazardous activities e.g. adventure sports, military or air-force operations
5. Initial Waiting Periods – (0 days / 15days / 30 days / or 90 days)
6. Specific Diseases , Disorders or Conditions specifically excluded upto the specified waiting periods (1 year / 2 years / or more)
7. Declared and Approved Pre Existing Diseases, Disorders or Conditions specifically excluded upto the specified waiting periods (0 days / 30days / 90 days / 1 year / 2 years / 3 years / 4 years / or more )
8. Diseases / Disorders / Conditions specifically permanently excluded
9. Survival Waiting Period in case of Critical illness Lumpsum Benefit plans  (0 days / 7 days / 15 days / 30 days / or more )
10. Unrecognized Physician or Hospital:

1. Treatment or Medical Advice provided by a Medical Practitioner not recognized by the Medical Council of India or by Central Council of Indian Medicine or by Central council of Homeopathy.
2. Treatment provided by anyone with the same residence as an Insured Person or who is a member of the Insured Person’s immediate family or relatives.
3. Treatment provided by Hospital or health facility that is not recognized by the relevant authorities in India.

Medical Exclusions

1. Illness or injury resulting from the use of alcohol, tobacco, narcotics or psychotropic substances
2. Unregistered Hospitals
3. Cosmetic, aesthetic and re-shaping treatment and surgeries unless required because of illness or injury
4. Out-patient basis treatment
5. Unproven/Experimental treatments
6. Admission primarily for diagnostics and evaluation only
7. Any diagnostic expenses not related/not incidental to covered illness
8. Run-down condition i.e. rehabilitation, convalescence
9. External congenital anomaly
10. Any form of hormone replacement therapy (HRT) and/or administration of other hormonal medication
11. Treatment and supplies for analysis and adjustments
12. Treatment rendered by a Doctor outside his discipline of system of Medicines
13. Treatment or drug not supported with prescriptions
14. Investigation & Evaluation
15. Rest cure, rehabilitation and respite care
16. Change-of-Gender treatments
17. Treatment in Excluded Providers
18. Wellness and Rejuvenation
19. Dietary Supplements and Substances
20. Venereal disease, or illness
21. Refractive Error less than 7.5 dioptres
22. Self-detachable or removal artificial body parts
23. Obesity / Weight Control ( mainly for cosmetic purpose and in absence of morbid obesity)
24. Dental treatment
25. Infertility, Sterility, Birth control
26. Treatment outside India except if opted for Global Coverage
27. Alternative treatments except to the extent opted or covered specially in Ayush Benefit
28. Hearing aids, spectacles or contact lenses except opted or covered in Special Treatment
29. Maternity expenses except when specially covered or opted
30. Non-payable items as per Annexure except when specially covered or opted

Please note above items nos. 24 to 30 can be customised to be covered in your Health insurance coverage

^For complete list & understanding of exclusions, read the Policy Terms and conditions

What is a Waiting Period in Health Insurance?

As the name suggests, waiting period is quite literally the amount of time you need to wait. And in a health insurance, it refers to the amount of time you need to wait for, from the start of your policy, to be able to use the benefits of it.

For example: One of the most common types of waiting period is the time you need to wait to be able to use special benefits such as a Maternity Cover; in this case most health insurers will include a waiting period of 1 to 4 years i.e. before you can actually benefit from the maternity cover, you should have your policy for at least 1 to 4 years (this amount of time is dependent on the health insurance policy you buy).

Types of Waiting Periods in Health Insurance

There are various kinds of waiting periods present in every health insurance policy. Let’s have a look at what they imply, what the industry average is, and what are Digit’s Health Insurance waiting periods in context to them all.

1. Initial Waiting Period

An initial waiting period, also known as the cooling period in health insurance, refers to the amount of time you’ll have to wait from the date of issue to actively start using your health insurance policy and benefiting from it.

Today, the standard in the industry, for initial waiting periods is up to 30 days with all health insurance policies.

2. Pre-Existing Diseases Waiting Period (PED)

Typically, when you buy a health insurance policy, you will be asked about pre-existing diseases, and/or will also be asked to take a few medical tests that may conclude the same.

As per the IRDAI (Insurance Regulatory Development Authority of India), a pre-existing disease refers to any condition, ailment, injury or disease that has been diagnosed  before buying your health insurance policy. 

Some examples of preexisting diseases include diabetes, hypertension, thyroid, etc. Thereby, if you do have a pre-existing disease, you will have to wait for the prescribed waiting period before you can claim for any hospitalization or treatment that is related to the disease.

Usually, the waiting period for the pre-existing disease is from one to four years, depending on your health insurer and type of health insurance plan chosen. In the modern days, Policies with day 1 coverage or day 31 or day 91 coverage for pre existing Diabetes, Hypertension and Asthma are also available in the insurance industry.

3. LIST OF COMMON SPECIFIC DISEASES NOT COVERED UPTO THE WAITING PERIODS

The title is perhaps self-explanatory, i.e. waiting periods for specific diseases imply that you will need to wait for the prescribed amount of time when it comes to claiming for treatment and hospitalization related to a list of specific diseases.

Generally, the waiting period for these situations is one to four years, and varies from insurer to insurer.

The list of specific diseases applicable for the above waiting period 

1. Non-infective Arthritis, Osteoarthritis and Osteoporosis (if age related), Systemic Connective Tissue Disorders, Dorsopathies, Spondylopathies, Inflammatory Polyarthropathies, Rheumatoid Arthritis, Arthrosis and Intervertebral Disorders & Surgeries for these ailments (unless due to accident).
2. Pancreatitis, Calculus disease of gall bladder/biliary tract and urogenital system, Gastritis, Duodenitis, Gastric &Duodenal Erosions/Ulcer; Erosions, Ulcers and Varices of gastro intestinal tract , Cirrhosis of Liver, Rectal Prolapse.
3. Eye: Cataract, Glaucoma and Disorder of Retina.
4. Hyperplasia of Prostate, Urethral Strictures, Hydrocele/Varicocele and Spermatocele.
5. All abnormal Utero-vaginal bleeding, female Genital Prolapse, Endometriosis / Adenomyosis, Fibroids, Ovarian Cyst, PCOD, Pelvic Inflammatory Disease, and hysterectomy (unless necessitated by Malignancy)
6. Hemorrhoids, Fissure, Fistula and Pilonidal Sinus / Cyst and Fistula, or abscess of anal and rectal region
7. Hernia of all sites & types.
8. Varicose veins of lower extremities.
9. Disease of middle ear and mastoid including otitis Media, Cholesteatoma, Perforation of Tympanic Membrane, Sinusitis, Tonsillitis, Adenoid Hypertrophy, Nasal Septum Deviation, Turbinate Hypertrophy, Diseases of Nasal Sinuses, Nasal Polyp, Mastoiditis, Nasal Concha Bullosa.
10. All internal and external benign or In Situ Neoplasms/Tumors, Cyst, Sinus, Polyp, Nodules, Swelling, Mass or Lump including breast lumps (each of any kind unless malignant).
11. Internal Congenital Anomaly.
12. Psychiatric illness and Disorders such as  Schizophrenia, schizotypal and delusional disorders, Mood [affective] disorders, Neurotic, stress-related and somatoform disorders and Unspecified mental disorders.
13. Neurodegenerative disorders including but not limited to Alzheimer’s disease and Parkinson’s disease.

The above list might vary from insurer to insurer.

Maternity Benefit & Newborn Baby Cover – Standard or General Exclusion / Inclusion with Waiting Period if Add-On Benefit available and if opted.

As part of most health insurance policies for individuals and families, there is an option to also include a Maternity Benefit and Newborn Baby (of age upto first 90days ) add-on for those planning a family soon and apart from just planning for the baby, it is wise to also plan financially for the expenses that arise during and post labor.

Typically, the waiting period with most health insurance policies ranges from one year to four years.

This means you can only claim for maternity-related expenses once you’ve completed one to four years of your policy.

Therefore, if you’re planning on starting a family sometime soon and would want to ensure your health insurance policy covers for it, then take in consideration the 9-months of the pregnancy term, plus the rest months to complete your one to four years waiting periods, based on the Maternity Health insurance plan you choose.

The maternity benefit add-on covers for delivery expenses and, the baby for its first 90 days; including its necessary vaccinations and any other medical care required otherwise.

Waiting Period for Bariatric Surgery

A bariatric surgery is included in some health insurance policies today. It refers to a surgery on the stomach and/or the intestines to help someone with extreme obesity related issues.

It is usually only recommended for those with a BMI above 35-40, and who are going through other health issues because of the same.

Annual Health Check-Up

Some health insurance policies, give  annual health checkups as part of your health insurance plan.

However, there is a sort of waiting period for this too.

One can avail of this benefit during renewals. This means you can get it only after completing 1 to 4 years of your health insurance policy, for claim-free years.

However, now a days, A few of notable insurance companies reimburse annual health check up costs upto the defined limit from day1, on cashless basis or reimbursement basis, irrespective of claims occurrence.

Summary of Health insurance Waiting Periods from the first day of being insured:

1. Initial Waiting period (0 days / 15days / 30 days / or 90 days)
2. Specific Diseases (1 year / 2 years / or more)
3. Declared and Approved Pre-Existing Diseases (0 days / 30days / 90 days / 1 year / 2 years / 3 years / 4 years / or more )
4. *Non-Declared Pre-Existing Diseases (0 days / 30days / 90 days / 1 year / 2 years / 3 years / 4 years / or more from the date of disclosure to the insurance company, provided the insurance company agrees to continue the policy with endorsement with or without additional premium , inspite of non-disclosure prior to the policy inception) *subjected to the decision of the insurer
5. Survival Waiting Period in case of Critical illness Lumpsum Benefit Health insurance plans (0 days / 7 days / 15 days / or 30 days )
6. Personal Waiting period & Specific Exclusions Waiting period

MODERN/ ADVANCED TREATMENTS SUBLIMITS :

1. The following Modern procedures / treatments will be covered on Inpatient Care or as part of Day Care Treatment , in a Hospital, either upto the sum insured or upto the defined sublimits on selected Health insurance plans.
2. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)
3. Balloon Sinuplasty

iii. Deep Brain stimulation

1. Oral chemotherapy
2. Immunotherapy- Monoclonal Antibody to be given as injection
3. Intra vitreal injections

vii. Robotic surgeries

viii. Stereotactic radio surgeries

1. BronchicalThermoplasty
2. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)
3. IONM – (Intra Operative Neuro Monitoring)

xii. Stem cell therapy: Hematopoietic stem cells for bone marrow transplant for haematological conditions to be covered.

Special condition applicable for robotic surgeries:

A sublimit of maximum INR 1 Lac will apply to all robotic surgeries, except the following:

1. Robotic total radical prostatectomy
2. Robotic cardiac surgeries

iii. Robotic partial nephrectomy

1. Robotic surgeries for malignancies

The above special condition varies from insurer to insurer.

4 Lists of Non-Payable item and service (shared in a separate pdf)

Annexure-1

Annexure-2

Annexure-3

Annexure-4

Claim Process

All Claims will be settled by In house claims settlement team of the company or TPA that is engaged by the insurer.

 If the Insured meet with any Accidental Bodily Injury or suffer an Illness that may result in a claim, then as a condition precedent to the Company’s liability, the Insured must comply with the following:

1. Cashless Claims Procedure

 Cashless treatment is only available at Network Hospitals. In order to avail of cashless treatment, the following procedure must be followed by the Insured:

1. Prior to taking treatment and/or incurring Medical Expenses at a Network Hospital, the Insured/ his or her repre-sentative must call the Company and request pre-authorization by way of the written form.
2. In case of Planned hospitalization, the Insured/Insured’s representative shall intimate such admission 48 hours prior to such hospitalization

iii. In case of Emergency hospitalization, the Insured/Insured’s representative shall intimate such admission within 24 hours of such hospitalization

1. On receipt of Insured’s pre-authorization form duly filled and signed by the Insured/ his or her representative, the Company’s representative then within 2 hours will respond with Approval, Rejection or an more information
2. After considering the Insured’s request and after obtaining any further information or documentation the Company has sought, the Company may, if satisfied, send the Insured or the Network Hospital, an authorization letter. The authorization letter, the ID card issued to the Insured along with this Policy and any other information or documentation that the Company has specified must be produced to the Network Hospital identified in the pre-authorization letter at the time of Insured’s admission to the same.
3. If the procedure above is followed, the Insured will not be required to directly pay for the bill amount in the Network Hospital that the Company is liable, and the original bills and evidence of treatment in respect of the same shall be left with the Network Hospital.

Pre-authorization does not guarantee that all costs and expenses will be covered. The Company reserve the right to review each claim for Medical Expenses and accordingly coverage will be determined according to the terms and conditions of this Policy.

1. Reimbursement Claims Procedure

 If Pre-authorization as per Cashless Claims Procedure above is denied by the Company or if treatment is taken in

a Hospital other than a Network Hospital or if the Insured do not wish to avail cashless facility, then:

1. The Insured or someone claiming on his/ her behalf must inform the Company in writing immediately within 48 hours of hospitalization in case of emergency hospitalization and 48 hours prior to hospitalization in case of planned hospitalization
2. The Insured must immediately consult a Medical Practitioner and follow the advice and treatment that he recommends.

iii. The Insured must take reasonable steps or measures to minimize the quantum of any claim that may be made under this Policy.

 List of Claim documents required for Reimbursement of Expenses in a Non-Network Hospital

• Claim form with NEFT details & cancelled cheque duly signed by Proposer / Claimant
• Original/Attested copies of Discharge Summary / Discharge Certificate / Death Summary with Surgical & anesthetics notes
• Attested copies of Indoor case papers (if available)
• Original/Attested copies Final Hospital Bill with break up of surgical charges, surgeon’s fees, OT charges etc
• Original Paid Receipt against the final Hospital Bill.
• Original bills towards Investigations done / Laboratory Bills.
• Original/Attested copies of Investigation Reports against Investigations done.
• Original bills and receipts paid for the transportation from Registered Ambulance Service Provider.

Treating Medical Practitioner’s certificate to transfer the Injured person to a higher medical centre for further treatment (if Applicable).

• Cashless settlement letter or other company settlement letter
• First consultation letter for the current ailment.
• In case of implant surgery, invoice & sticker.
• In cases where a fraud is suspected, insurer may call for any additional document(s) in addition to the documents listed above
• Aadhar card & PAN card Copies (Not mandatory if the same is linked with the policy while issuance or in previous claim)

You will have to Submit all original documents to the insurer within 30 days of discharge.

Insurance companies will process the Claim and update you the status within maximum 30-45 days from the date of receipt of last necessary documents. We will also lend a helping hand to you for the insurance company speeden up the process of settlement of the claim.