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Learn about the Health Insurance Terminologies that Challenge you

By Vikas Chandra Das
03 October 2022, 11:41 AM

You will find many estimates if you are looking for a health insurance plan in India. Each document includes critical information about policy coverage and criteria. You must review the paperwork and grasp every phrase to evaluate financial safety and coverage. Even so, some of the terminologies in health insurance policies might be confusing. You could avoid making costly mistakes if you understand the intricacies of your health insurance policy. Understanding health insurance becomes a difficult task because of the jargon used in the segment. This article will decode the jargon for you and make your work easier. 

1. Add-ons or Riders

Add-ons/riders are extra health insurance features, also known as optional coverage — a component that provides additional financial protection against unanticipated medical conditions requiring significant treatment expenditures.

Critical illness cover, maternity cover, room rent waiver, hospital cash benefit, and other overs supplement your primary health insurance plan.

2. Comorbidities/Pre-existing Diseases

Regarding health insurance, comorbidities such as COPD, hypertension, diabetes, renal difficulties, cardiovascular troubles, and other underlying disorders are considered serious health issues. Patients with such pre-existing medical issues are made to pay a higher premium.

3. Co-payment

Some health insurance policies include a co-payment or co-pay provision. It is a set proportion of the sum that the insured/policyholder must pay to the insurance company before getting healthcare services. For example, the policy wordings stated that those over 60 must pay a 20% co-pay each time they raise a health insurance claim.

It is crucial to remember that under such circumstances, the insurance provider does not lower the sum insured. It is more probable that a senior health insurance plan will include this benefit.

4. Critical Illness

Critical illnesses — sometimes called life-threatening medical problems — are ailments such as cancer, renal failure, and cardiovascular disease. Specific medical insurance programs cover these diseases. You can also purchase a rider or add-on cover for the same.

5. Cashless Claim

Cashless claims mean the policyholders don’t need to make upfront payments for the treatment up to the eligible amount. However, this facility is available only at the network hospital of the insurer.

6. Deductibles

It is critical to understand health insurance deductibles. Deductibles can lower your policy premiums while requiring you to pay a certain amount when filing an insurance claim. It may sound similar to a co-payment clause but is different. Here the coverage begins as soon as the health expenditure crosses the deductible limit. So, if the sum insured is INR 8 lakh and the deductible is INR 3 lakh. The insurance company will cover once that INR 3 lakh limit crosses. But if your treatment costs fall below INR 3 lakh, the entire liability will be yours. 

So, look for the deductible provision in the insurance paperwork and select the one that does not include it until you are ready to face the treatment costs.

7. Inclusions

It is something you must thoroughly investigate. Coverage benefits, also known as inclusions, are the expenditures and perks for which the insurer will reimburse you. It covers hospitalisation costs, ambulance fees, surgery, hospital room bills, anaesthesia, medications, and treatment-related expenses.

8. Family Floater Health Insurance

As the name implies, blood or legal family members can buy this policy. The insured money is divided by all family members. 

9. TPA

TPAs or Third-party Administrators are professional organisations organising and managing health insurance claims and other associated services. To commence the claim procedure, the policyholder must contact the TPA (usually present in the hospital). TPA serves as a conduit between the insured and the insurer.

10. Waiting Period in Health Insurance

A policyholder cannot file a claim during this period. A waiting time is typically applied to pre-existing conditions, maternity benefits, etc. A waiting period in health insurance might last from a few months to several years. This usually is a specified time from the date of policy initiation, after which certain particular policy advantages take effect. For example, the waiting period for pre-existing conditions is four years. As a result, purchasing health insurance coverage as early as possible is advised. 

What Makes Health Insurance so Important?

India's economy is clearly among the fastest-growing in the world, but on the flip side, it is also a refuge for several ailments. Many diseases are curable in India now that medical knowledge has advanced, but the expense of treating such illnesses may cramp your wallet. Many people have their needs met by the health insurance provided by their employers, but it isn't a long-term fix. The employer-provided health benefits or insurance coverage is only valid while employed there; if you leave the firm, you lose all collected benefits and coverage.

Hence, health insurance is becoming necessary with our country’s healthcare costs constantly growing and illness outbreaks rising. Customers who purchase health insurance get a much-needed financial safety net in a medical emergency. Uncertainty and health hazards are inevitable components of life. One cannot plan for illness, but one can prepare for the financial part. Purchasing health insurance is one approach to being financially prepared for unforeseeable health risks.

Health insurance is a sort of insurance that covers the insured's medical expenditures. Health insurance can repay the insured for illness or injury-related expenses or pay the care provider directly. 

Individual health insurance, family plan, critical illness insurance, and other plans are available to cover you. Purchasing health insurance has become an essential element of financial planning.

Read more - Top #5 Smart Things to Know About Optimizing Your Health Insurance Benefits


So, now you know some of the healthcare terms while looking for the best health insurance coverage. We believe you will agree that some prior information will go a long way in making sense; this will enable you to make sound decisions for yourself and your family, particularly about medical insurance.

Read more - What is Loading In Health Insurance Policies


1. How do cashless facilities work?

As part of their network, insurance companies have affiliation agreements with several nationwide hospitals. Using a cashless facility, policyholders can receive treatment at any cashless network hospital without paying the hospital bills since the insurance company pays the hospital on their behalf through the TPA. However, you must pay the hospital directly for any costs that exceed the insurance policy's limits or sub-limits or those not covered. However, the cashless facility will not be available if you receive treatment at a hospital not part of the network.

2. Are insurance claims subject to a waiting period?

Yes. When you buy new coverage, there is often a 30-day waiting period after the policy's start date, where the insurance companies won't cover any hospitalisation costs. However, this does not include emergency hospitalisation resulting from an accident. If you have any pre-existing illnesses, the waiting period would stretch to four years. 

3. In a health insurance policy, what is a pre-existing condition?

It is a physical problem or disease that predates your purchase of health insurance, which is essential since insurance companies do not cover such pre-existing diseases within 48 months of purchasing the first policy. After 48 months of continuous insurance coverage, the insurer may consider covering pre-existing conditions.

4. Which points should I consider before buying a health insurance policy?

  • The type of health insurance plan. 
  • The elements that the policy covers.
  • The aspects that are not covered by the policy 
  • Check if your policy provides regular health check-ups. 
  • Price of the plan and the parameters for deciding the premium amount. 
  • Ask if you can choose the doctor of your choice or if you have to get treated by the doctor they provide. 
  • Most importantly, check the number of claims you can file in a year. 

5. How is the treatment for cancer covered by health insurance?

When you buy cancer insurance, you receive a predetermined sum as the maximum sum insured if diagnosed with cancer. 

However, the insured sum may not be paid out in full right away. 

If you are diagnosed with early-stage cancer, you may be entitled to 25% of the total sum insured. The remaining 75% of the insured amount will be paid to you in a lump sum if your current medical condition develops into late-stage cancer. 

If you receive a direct diagnosis of late-stage cancer, you may be eligible to receive a lump sum payment equal to 100% of the insured amount.

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