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The Concepts of Health Insurance explored

By  , Expert Content
Jan 14, 2013
4.8 / 5(4 Ratings)

Health InsuranceWhat is a network?


Ans. This term is used whether the hospital is empanelled with insurance company/ TPA or not. If it is then it is called as network hospital of the insurance company.

 

What is Domestic Travel Insurance?


Ans. This is travel insurance –when you are traveling within India.

 

What is coverage amount ?


Ans. Coverage amount is sum assured .This is the maximum amount which the insurance company will pay in the form of claim. The company may put sub-limits on the sum assured in the form of room rent etc. Please see the policy language carefully.

 

What do you mean by Cashless Hospitalization?


Ans. The Insurance Company or the TPA (Third Party Administrator) working on behalf of Insurance Company gives instruction to the hospital to treat the insured person and do not collect the payment from the insured/patient – but to send the bills to them (Insurance Company or the TPA) for payment. This is what is called Cashless Hospitalization.

 

What problems can you face when you change your health insurer and try claiming money for hospitalization charges for treating pre-existing ailments?


Ans. The new Insurance Company will not pay for pre existing disease. You should continue with the existing insurance company as it is legally bound to pay for future hospitalizations with same disease. It is a safer bet for you.

 

What should I keep in mind before obtaining services from TPA?


Ans. Keep policy number / ID Card No. handy. Prescription of doctor advising hospitalization, who will conduct procedure/ surgery in hospital, what is the treatment to be given, what is estimated cost, Expected date of admission into hospital and for no of days you will be in hospital. TPA will ask these questions and will ask you to submit / fax these documents.

 

Who is a Third Party Administrator?


Ans. TPA is an abbreviation for Third Party Administrator. These companies are BPO’s of insurance companies and are responsible for coordinating all aspects of claims pertaining to health insurance policies.

These companies are licensed by IRDA (Insurance Regulatory & Development Authority) and are having

  • Telecom facility generally with phone number starting with 1600 (toll free no.)

  • Computer network having details of all policies holders.

  • Medical specialists, for assessing need for hospitalization treatment being given in the hospital and for passing of the claim bills.

 

What is the basic difference between individual and group health insurance coverage?


Ans. Individual Health insurance is what you buy as a family of 1 to 6 persons. Oriental Insurance is the one which gives Oriental Happy Family Floater Policy, where a  family of upto 10 persons can be covered. Group Health Insurance policy is what is issued to a corporate or a group or to an association and covers a group (generally more than 100 persons). The positive point in a group policy is that you can negotiate special terms like;

  1. Maternity coverage is available.

  2. Pre existing disease is covered.

  3. No medical examination, even if you are above 45 years.

When a member leaves the organization you can add the new member as a substitute for the one whose name is deleted.

Rates in the case of a group policy can be attractive. For very large group of say 1,00,000 the rates are very attractive.

 

What should I keep in mind before obtaining services from TPA?


Ans. Keep policy number / ID Card No. handy. Prescription of doctor advising hospitalization, who will conduct procedure/ surgery in hospital, what is the treatment to be given, what is estimated cost, Expected date of admission into hospital and for no of days you will be in hospital. TPA will ask these questions and will ask you to submit / fax these documents.

 

What are the benefits of floater plan?


Ans. Family floater policy is giving you better rates. If you have a normal policy then every member is eligible for sum mentioned against his name. In family floater sum is for the family so any one/ some/ all family members can lodge claim.

 

What happens in the event of an injury or illness that demands immediate medical attention?


Ans. Life is important. Injured / patient should be taken to doctor / nearest nursing home/ hospital and emergency treatment should be provided. At appropriate time if necessary the patient can be moved to an empanelled hospital in consultation with the insurance company/TPA.

 

S.K. Sethi, Vice President of Insurance Foundation of India answers 10 most frequently asked questions about Health Insurance.

 

 

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Comments
  • joby10 Feb 2013
    wanna put some mediclaim looking for a bettr company