100+ Health Insurance Terminologies A to Z

Strangely, only a few people in the industry know the basic health insurance terminologies of financial products, the rest depend on the Front Line Sales force, but wait, this dependency is also of almost no use. Front Line Sales are required to provide practical product knowledge and information about the company’s internal processes to drive sales for the company, not to provide the pros and cons of each terminology and the insurance company disclaimer is that please go through “Policy Wording”. So, it must need to know the basic terminology in very simple words.

Due to the pressure of Target, FLS and Agents also miss-selling to the customer which has become very common nowadays.

Then what should one do if one is a master in his/her field but should have basic knowledge of personal finance/Insurance so that customers are aware of their product features and how they work?

In addition to this, questions were raised that customers should not have complete dependency on their agents/relationship managers, but also need to search online for basic knowledge purposes, there is also a problem faced by customers that search online for basic information, they will get multiple phone calls and only product brochure information not the terminology of particular products.

Many individual bloggers/writers do a great job of making people aware of customers in this. Here is the A to Z terminology mentioned with their meaning in simple words

A

Annexure, Accident, AYUSH, Ayush Day Care, Acute Condition, Adventure/hazardous sports, Age, Ambulance, Annual Health Checkups, Associated Medical Expenses, Alzheimer’s Disease, Aorta Graft Surgery, Aplastic Anemia, Automatic Cancellation, Additional Premium, Addictive Conditions, Assisted Reproduction Services, Activities and Profession Exclusions, Availing Cashless Facility, Auto Pay (NACH), Alteration of Policy, Arbitration Clauses, Accidental Death Cover

Annexure– Annexure of List of the entire list mentioned all the list of expenses and items

Accident– Any type of Accident whether road traffic or domestic

AYUSH– Alternative treatments other than Allopathy Treatment, including Ayurveda, Yoga, Unani, Siddha, Homeopathy

Ayush Day Care– Day Care treatment methods other than Allopathy

Acute Condition–

Adventure/hazardous sports– Sports that need to be done under the supervision of trained professionals and registered with the Ministry of Tourism excluding the regular profession

Age– Age of All Insured Members

Ambulance – The vehicle by which the insured person is taken from any place where he is sick to the hospital

Annual Health Checkups– The insurance company covers a fixed pathology/diagnostic medical test every year or for a fixed amount, in its health insurance plans.

Associated Medical Expenses– these include consultation fees, OR Charges, all kinds of surgical instruments expenses all kinds of pathology charges excluding the pharmacy charges

Alzheimer’s Disease–

Aorta Graft Surgery

Aplastic Anemia

Automatic Cancellation– The policy will terminate automatically if the policyholder death and the refund will proceed on a pro-rata basis if the claim is not taken in that particular policy year, but other insured persons’ cover will be in force and they can renew the policy, the condition is that they belong to the proposer legal heirs. Sometimes Insurance Company will terminate the policy if a false claim is logged any fraudulent claim activity by the policyholders, or non-disclosure of any previous medical history before the policy buy, and any profession where the insurer will not offer the health insurance based on non-disclosures

Additional Premium– The insurance company can also charge some additional premium taking into account the health, medical history or lifestyle habits of the applicant, this is called an additional premium/loading premium.

Addictive Conditions – When a person uses an intoxicating substance, he/she becomes addicted to it and cannot leave it.

Assisted Reproduction Services

Activities and Profession Exclusions– Some activities and professions are not covered by health insurance because they involve health risks.

Availing of Cashless Facility– Cashless facility means that the policyholder can get his treatment by visiting the network hospital and after taking the approval of the insurance company, he does not have to pay money to the hospital, cashless facility does not guarantee that the policyholder will be treated on cashless basis, They provide you careless facility as per the term and condition of the policy of the insurance company. This information can be obtained from the official website of the insurance company or by calling customer care.

Auto Pay (NACH)– As we know the health insurance contract is for 365 days and the policyholder has to renew it every year, the policyholder can collect the premium for 2 years or even 3 years. And if the policyholder wants to auto-pay his premium then he has to fill out a “Standing Instruction” form, this can be done either online or offline.

Alteration of Policy– Any changes in the policy

Arbitration Clauses– Both the policyholder and the insurer can appoint an arbitrator to resolve any dispute

Accidental Death Cover– Any claim given in case of any kind of accidental death is called Accidental Death Cover.

B

Bone Marrow Transplant, Bank Rate, Base Sum Insured, Bacterial Meningitis, Break in Policy, Biological Attack or Weapons, BMI, Breach of Law, Behavioural Exclusions, Black Listed Hospitals

Bone Marrow Transplant– In the actual transplant of a human organ, the main ones are the heart, lung, liver, kidney, and pancreas, which result from the irreversible end-stage failure of the relevant organ and the concerned doctor should also recommend it.

Bank Rate-Bank rate in health insurance means whatever rate the claim is pending in any policy year, and if the insurance company has to pay that claim to the particular year then whatever bank rate RBI has kept will be the same rate of interest with an additional 2% will have to pay to the policyholder

Bacterial Meningitis– bacterial meningitis is a type of bacterial infection that is also treated in health insurance plans, but the condition is that it should be justified.

Break in Policy– Break in policy means that the policy will be in the grace period of the policy till renewal and on any day between the policy expiry and policy renewal, any kind of hospitalization/daycare accidental injury will not be covered. Break in Policy happens in two ways, one is renewal after the due date and the second is when the policyholder ports to another company after the policy of the previous insurance company has expired, the policy is issued in a new insurance company, there is a risk in the new company. cover start date policy will be issued after the issue.

Biological Attack or Weapons– Whatever disease is caused by any kind of chemical attack, the person becomes completely or partially disabled, even death

BMI– Body Mass Index means the ratio of height and weight of the insured person.

Breach of Law– Any type of hospitalization or treatment by the insured person that violates our law, such as assault or illegal restraint or any injury resulting from such treatment, is not covered by the health insurance company.

Behavioural Exclusions – Behavioral Exclusions arise in the situation when the insured person is injured in making a suicide attempt, indulges in illegal activities, intentionally offends someone, consumes any kind of subtational abuse, uses any kind of drug without permission of a doctor, is Health insurance does not cover any kind of treatment due to these.

Black Listed Hospitals– Black Listed Hospitals are those hospitals that are blocked by the insurance company based on any kind of misrepresentation or fraud, and if any hospital is blocked by even one insurance company, then all the hospitals are blocked. This is done to stop file scams in the insurance industry. If the policyholder gets his treatment done in any hospital then his reimbursement claim will not be paid by the insurance company, until unless extreme medical emergency and it will be a completely one-sided decision of the insurance company whether to pay or not depending upon the stringent investigation process. by 3rd party instigator of the insurance company.

C

Condition Precedent, Congenital Anomaly, Co-Payment, Coma of Specified Severity, Chronic Condition, Cancer Treatment, Cardiac Arrest, Chemical Attack or Weapons, Commencement Date, Coronary Artery By-Pass Surgery, Cerebral Aneurysm – with Surgery or Radiotherapy, Custodial Case, Co-Morbidities, Change of Gender Treatment, Circumstantial Exclusion, Circumcision, COPD, Cochlear Implant, Cancellation, Claim Settlement, Condition Precedent to Admission of Liability, Complete Discharge Claim, Claim Documents, Critical Illness Cover, Claim outside India, Claim Assessment and Repudiation, Communication and Notice, Compassionate Visit, Claim Sequence.

Condition Precedent– means, the policy period in which the insurer has liability.

Congenital Anomaly– means a medical condition in an insured person since birth, it is two types one is visible called external and another is invisible called internal

Co-Payment– means some parts of the claim amount must be paid by the policyholder from their pocket and the rest by the insurer.

Coma of Specified Severity– When an insured person is in such a situation when he has lost all sense of function but is alive, and is not trying to fulfill his needs like daily activities, food etc.

Chronic Condition– When any person has any such medical condition, injury occurs and its treatment continues continuously, like diabetes, BP, cholesterol, Asthma, Thyroid and can be others that require continuous treatment and care sometimes lifelong.

Cancer Treatment– all types of cancer treatment after taking the policy, it might be a few initial waiting periods like 30 days, 60 days, 90 days or 180 days, depending on the insurance plan

Cardiac Arrest -A cardiography test as evidence of heart-related disease is a requirement of the insurance company

Chemical Attack or Weapons– When there is any kind of chemical attack, whether it is in the form of solid or gas, it can also be in the form of liquid, as a result of which the person can become sick or handicapped or can even die

Commencement Date -means the commencement of risk cover with the insurer as per policy terms & conditions

Coronary Artery By-Pass Surgery, Cerebral Aneurysm – with Surgery or Radiotherapy– heart disease surgery

Custodial Care-Means taking care of a sick person’s daily routine, such as giving medicine on time, sending food

Co-Morbidities– This means an additional medical condition that is related to the medical condition

Change of Gender Treatment – Means the gender change surgery

Circumstantial Exclusion– Any medical treatment in case of war, invasion, military involvement, nuclear weapon attack, chemical attack or direct involvement of the insured person is not covered in the policy.

Circumcision– A type of medical surgery that involves removing the foreskin tissue of the male genitalia that is not covered by health insurance.

COPD– Chronic Lung Disease

Cochlear Implant– A kind of special device by which an outsider increases the power of hearing.

Cancellation– The policy can be cancelled by either the insurer or the insured person.

Claim Settlement-The health insurance company will reject or accept the claim within 30 days of receiving the claim documents, if the claim requires some kind of field investigation the company will have to do this investigation within 30 days and the claim will take 45 days. Will it be accepted or rejected, if it takes more days and if the claim is accepted then the insurance company will pay 2% interest on the claim amount in addition to the bank rate to the policyholder.

Condition Precedent to Admission of Liability- This means If the policyholder follows all the rules as per the policy then the insurer is bound to pay the claim.

Complete Discharge Claim– This means the insurer has given the right to all claims to the policyholder/or his/her legal heirs or the insured person till the time he/she is discharged from the hospital.

Claim Documents– list of documents on which the insurer will decide whether to accept or reject or raise additional queries if any.

Coronary Heart Diseases- heart disease

Critical Illness Cover– means it is different from the indemnity plans where if any listed critical illness is diagnosed, then after the survival period and the company’s own internal process and investigation, the company will pay to Sum Insured amount to the policyholder or their legal heir to their bank account.

Claim outside India– If any hospitalisation/treatment outside India

Claim Assessment and Repudiation– We often hear this word that the claim has been repudiated, that is, the cashless claim has been rejected for the time being and the policyholder has to file the reimbursement after the investigation if everything is found to be correct then the claim will have to be paid otherwise it will not happen.

Communication and Notice– The insurance company and the policyholder are authorized to receive or send any type of communication, provided that both parties are not authorized to send any communication to a third party, whether virtual or physical.

Compassionate Visit– When relatives or friends come to see a sick person or a dying person, it is called a compassionate visit.

Claim Sequence- We often hear that like base cover, NCB, reload, super reload, super NCB etc., all these in health insurance policies have a sequence which is called claim sequence, this sequence is like, Base Claim, NCB, Super NCB, Reload/Recharge/Refill, Super Reload/Recharge/Rifil, Unlimited Reload/Recharge/Refill and then any top-up policy or super top-up policy is available

D

Day Care Centre, Day Care Treatment, Deductible, Dental Treatment, Deafness, Disclosures of Information, Domicialiry Hospitalization, Dependent Child, Diagnostic Expenses, Dietary Supplements that can be purchased without prescription, Discount, Durable Medical Equipment Cover

Day Care Centre– means any institute or establishment in which day care procedures are performed, has full-time qualified nursing staff, medical practitioner, operation treater and daily records are maintained.

Day Care Treatment– In today’s modern times, there is no need for the policyholder to be admitted to the hospital for 24 hours for the treatment of some diseases or surgery, hence it is called day care treatment, it will be covered only when that particular day care treatment is covered in the policy

Deductible– In some insurance plans, on the first claim of every year, a certain amount of admissible claim like Rs 20K, 25K, 50K or whatever is deducted as per the plan.

Dental Treatment– Medical expenses related to dental treatment

Deafness– Inability to hear in both ears and it cannot be corrected

Disclosures of Information– Disclosure of all aspects by the insurance applicant to the insurance company like, medical-related, lifestyle-related, if a high-value sum is insured to the financial capabilities of the insurance applicant.

Domiciliary Hospitalization– treatment procedures in which the insured person can undergo the treatment at home, if a hospital bed is not available or as per the treating doctor, the treatment can be administered at home also or if the insured person is unable to stay in the hospital.

Dependent Child– Children of the policyholder who are financially dependent on him

Diagnostic Expenses– Whatever type of pathology test, radiology test, or sonology test is done to verify the clinical evidence of the disease, it should be kept in mind that all these diagnostic expenses are related to the particular illness.

Dietary Supplements that can be purchased without prescription- Any type of dental supplements available without a prescription from the treating doctor, such as vitamin pills, protein powder, etc., is not covered by health insurance

Discount– In health insurance, the premium policyholder can pay simultaneously for 2 years or even 3 years as they generally get 7.5% and 10% discounts respectively and a document is also given on renewal to maintain a good lifestyle of the insurance policyholders.

Durable Medical Equipment Cover– Means ventilators, wheelchairs, prosthetic devices, etc., which some health insurance companies cover as optional cover.

E

Emergency Care, Emergency Assistance Services Provider, End Stage Lung Failure, End Stage Liver Failure, Experimental Treatment, Empanleed Service Providers, Evidence-Based Clinical Procedures, E- Consultation, Excluded Providers, Ectopic Pregnancy, ECP, EECP, Endorsement, , Electronic Transaction,

Emergency Care– A person’s health suddenly worsens and he needs immediate treatment. This type of medical treatment is called emergency care.

Emergency Assistance Services Provider– means the road/air ambulance, that provides the services during the emergency of medical conditions.

End-Stage Lung Failure– When a person’s lungs reach the last stage of chronic respiratory disease.

Experimental Treatment– any kind of treatment belonging to experimental purpose, is not covered by health insurance

Empanelled Service Providers- are the service providers that have an agreement with insurers, such as network hospitals, diagnostic centres, pathology services etc.

Evidence-Based Clinical Procedures-Means any line of ineffective treatment being taken for that particular disease.

E- Consultation– any kind of virtual communication to policyholders regarding health and lifestyle

Excluded Providers– Blacklisted Hospitals, Diagnostic Centres

Ectopic Pregnancy-means a pregnancy-related medical adversity, and it is not covered by health insurance.

ECP–Extracorporeal photopheresis 

EECP-Enhanced External Counterpulsation

Endorsement– Changes in any type of policy whether financial or non-financial, like change of address, mobile no, email ID, proposer, member addition, member deletion, or split policy, and it will be done by the insurance company.

Electronic Transaction– When a person buys a health insurance policy, he can buy it online or offline, when he buys it online, he gives all the necessary information to the insurance company through an electronic medium and the insurance company also buys its record, that is, voice telemedical recording, video medical recording. It can also be in the form of a physical medical, to which both parties, the insurer and the insurance applicant, agree.

F

Fulminant Viral Hepatitis, Femto Laser Surgery, Free Look Period, Faud, Financial Underwriting, Family Floater

Fulminant Viral Hepatitis– liver disease

Femto Laser Surgery– This is a type of advanced laser surgery especially used for eye LASIK and cataract surgery

Free Look Period– If the policyholder sends a cancellation request within the first 15 days of the issuance of the insurance policy, no cancellation charge is to be paid to the policyholder if the cancellation request is received within this period.

Fraud– This means any kind of irregularity in treatment, misrepresentation, fake claims, claim mafia.

Financial Underwriting– When an applicant applies for a very large sum insured, the insurance company also does financial underwriting of the applicant to find out what is the financial status of the applicant.

Family Floater– Family Floater Cover in which all the members of the family are covered under the same Sum Insured,

G

Grace Period, GIFT (Gamete intrafallopian transfer),; gestational surrogacy, Growth Hormone Therapy, Geographical Exclusion

Grace Period– This means, the period of 30 days till the policyholder’s policy expires is known as the grace period, beyond this the policyholder can renew his policy, but if he misses any medical emergency during this period, he will not get any claim.

GIFT– Gamete intrafallopian transfer

Gestational surrogacy

Growth Hormone Therapy– When growth hormone therapy is used to artificially make a child grow, it is not covered by health insurance.

Geographical Exclusion– Such areas/locations where treatment is not covered

H

Hospital, Hospitalization, Hospital outside India, Home Treatment, Heart Transplant, Heart Valve Replacement, Hazardous or Adventure Sports, Hormone Replacement Therapy, Hyperbaric Oxygen Therapy, HIV/AIDS and STD Cover

Hospital– a recognized place or institute/ medical college where treatment is taken or will be done

Hospitalization– The process of admitting an insured person to a hospital for treatment

Hospital outside India– a hospital which is outside India

Home Treatment– When the insured person is treated at his own home

Heart Transplant– When the insured person has heart end-stage failure, the insurance company covers his transplant treatment.

Heart Valve Replacement– This means heart valve replacement/repair surgery

Hazardous or Adventure Sports– Any kind of extreme and adventure sports in which there is a risk of injury, partial or total disability and death.

Hormone Replacement Therapy

Hyperbaric Oxygen Therapy– When a sick person is being given pure oxygen during treatment

HIV/AIDS and STD Cover– It is covered in some policies and not in some policies, it must be checked once during policy boarding.

I

Illness, Injury, In-Patient Care, Intensive Care Unit (ICU), ICU Charges, ICSI (intracytoplasmic sperm injection), Insured Person, IRDA, Investigation & evaluation, IVF (In vitro fertilization), Intimation of Claim, Individual Cover, Initial Waiting Period, Insurance Ombudsman

Illness– Means any disease or condition in which a person needs treatment

Injury– means any kind of accidental injury

In-Patient Care– during the treatment course in hospital

Intensive Care Unit (ICU)– When a seriously ill person is kept under observation in a place where he is treated with additional medical attention and has all the necessary medical equipment and this place is separate from the normal ward or room.

ICU Charges– Medical expenses of keeping a sick person in ICU, in some policies its limit is 2%, 5% of the sum insured and in some plans up to the sum insured.

ICSI – intracytoplasmic sperm injection

Insured Person– Means a person whose treatment is covered by a health insurance company as per the terms of the plan

IRDA– Insurance Regulatory and Development Authority

Investigation & Evaluation– Due to the disease due to which the insured person is admitted to the hospital if a Diagnostic, Pathology, Radiology, or Sonology test related to that disease is done then it is justified and it is covered under health insurance.

IVF– (In vitro fertilization), is not covered by the health insurance

Intimation of Claim– Claim Intimation to insurance company This is a kind of fraud prevention mechanism, it has some uses, if the insured person goes for treatment on a non-network then the insurance company has to be informed over call, if the hospital will be blacklisted in such a situation. In case of an accident, the insured person or any person on his/her behalf has to inform the insurance company within a stipulated day, for this, by calling the Call Centre, sending an Email, sending a Fax, writing to the office address of the insurance company with the following details, policy no, insured person name.

Individual Cover– Health insurance cover for a single member

Initial Waiting Period– In the case of health insurance, the risk cover starts from the date of policy issue, whereas in the case of an accident, the risk cover starts from the policy issue date, in the case of critical illness and cancer cover, the cover starts after 30 days. This can be for 60 days, 90 days or even 180 days, it varies from plan to plan.

Insurance Ombudsman– means an Institute that settles the dispute between an insured person and an insurer, and it is governed by govt of India

K

Kidney Failure Requiring Regular Dialysis, Kidney Transplant Surgery in case of End Stage Renal Failure, KTP Laser Surgery, Kidney Stone, Know Your Customer

Kidney Failure Requiring Regular Dialysis– When a person’s kidneys fail/fail and require regular blood transfusions, this is covered as a daycare procedure under health insurance.

Kidney Transplant Surgery in Case of End Stage Renal Failure-When a person’s kidney is completely damaged the kidney has to be changed on the recommendation of a specialist doctor.

KTP Laser Surgery–

Kidney Stone– When a person has a stone in his kidney, this condition is called kidney stone, in the latest policy of health insurance, its practice period is 24 months and if it is earlier then it is 36 months or even 48 depending on the plan.

Know Your Customer– KYC means know your customer, by their identity proof, it includes address proof, identity proof and bank proof.

L

Loss of Speech, Life-Threatening Situations, Live In-Partner, LGBT, Lung Transplant Surgery in case of End Stage Lung Diseases, Liver Transplant in case of end-stage liver failure

Loss of Speech– If a person loses his voice due to injury or disease and continues to lose his voice for 12 months, such a situation should be certified by an ENT specialist, it is called Loss of Speech.

Life-Threatening Situations– If there is any suspicion of any medical condition or disease not related to any pre-existing disease and the person still needs immediate treatment, even if his condition does not become normal.

Live In-Partner– not a married couple, but living together

LGBT– a kind of sexual orientation

Lung Transplant Surgery in Case of End-Stage Lung Diseases – When a person’s lung disease reaches the last stage, as per the recommendation of a specialist doctor, this surgery is done to diagnose it.

Liver Transplant in case of end-stage liver failure– When a person’s liver disease reaches the last stage, as per the recommendation of a specialist doctor, this surgery is done to diagnose it.

M

Major Organ Transplant, Medical Advice, Medical Expenses, Medical Practioner, Migration, Myocardial infarction, Maternity Expenses, multiple sclerosis persistence treatment, Material Facts, Major Illness, Muscular Dystrophy, motor neuron disease with permanent symptoms, multifocal Cases, Moratorium period, Multiple Policies Claim, Material Change, Medical Underwriting, Mid Term Member Addition, Mental Illness, Multi-individual

Major Organ Transplant– if any endstage organ of and transplant needs upton the specialities doctor advice, liver, kidney, heart, lung, pancreas and bone marrow.

Medical Advice– any advice related to the treatment or follow-up by the doctor.

Medical Expenses– All such medical expenses as may be recommended by a doctor due to illness or accidental injury.

Medical Practioner -means a person who holds valid registration of Medical Council of India or any Indian State Medical Council, for allopathy or in case of alternative medical treatment (AYUSH), keeping in mind that the medical practitioner and the insured person are residing in the same house. to, your advice will not be valid, because there will be a conflict of interest. If there is treatment covered in any policy out of India then the medical council of our particular country should see valid registration.

Migration– When a policyholder changes his plan in the same insurance company, it is called policy migration and he gets continuity benefits as per the rules of IRDA, but always keep one thing in mind you have to apply for migration 30 days before the renewal date. And the policy to which you are migrating will also have proper medical underwriting.

Myocardial infarction– First-time heart attack.

Maternity Expenses– expenses related to maternity childbirth, normal delivery and C-Section, in a normal health insurance indemnity plan Maternity Coverage is excluded but it is available as an optional cover and there are some waiting periods and limits & sub-limits applicable as well.

Multiple sclerosis persistence treatment–

Material Facts– all the relevant facts and information related to health insurance that is filled in the proposal form to evaluate the risk.

Major Illness– means all the major illnesses listed on the policy wording of the health insurance plan in the Annexure.

Muscular Dystrophy– means muscle-related disease.

Motor neuron disease with permanent symptoms-

Multifocal Lenses– A glass which, when placed in the eyes, enables a person suffering from nearsightedness and farsightedness to see clearly without the help of any additional glasses.

Moratorium period– If any health insurance is continued with the same company for 8 years, the insurance company cannot reject any kind of claim, exception Misrepresentation, Fraud or listed permanent exclusion, although co-payment, non-medical expenses, limit, sub-limits will apply as per policy terms and conditions if any.

Multiple Policies Claim– means if a person has taken multiple policies and a claim is triggered, it is called use multiple policy claim, this can be understood from the example like Mr A has an accident and one of his legs is broken, now we will get Hospitalization claim from Indemnity policy and he has passed personal accident policy to pair, due to injury he has to take bed rest for 3 months to cover his loss of income as TTD of Personal Accident policy. will cover benefits

Material Change – If the insured person is diagnosed with a particular medical condition, even if we write that we have not taken a claim for that particular medical condition, we will still have to inform the insurer that I have been diagnosed with a particular medical condition and keep it in your records, in case anyone in the future No matter what kind of claim is made, the complainant will not be asked for a first consultation letter regarding such medical condition.

Medical Underwriting– The process of doing medical risk evaluation by analyzing the present medical condition and past medical history of the policy applicant is called medical underwriting.

Mid-Term Member Addition– means a member addition during the policy years, it is generally done by an insured person when a member addition after marriage, after a new baby is born, in this condition, a new member premium will be taken on a pro-rata basis.

Mental Illness– Mental illness leads to mental instability.

Multi-individual– This means there are multiple members in the same policy and each has different health insurance coverage.

N

Network Provider, Non-Network Provider, Notification of Claim, Neuro Surgery, Nomination, No Constructive Notice, Non-Financial Transaction, Non-Medical Underwriting, No Claim Bonus

Network Provider- means hospitals, diagnostic centres, and pathology labs, that have a mutual agreement with the insurer company

Non-Network Provider– means hospitals, diagnostic centres, and pathology labs, that do not have a mutual agreement with the insurer company.

Notification of Claim– means notification of any claim through TPA or proper means of communication

Neuro Surgery-Surgery for human brain-related diseases.

Nomination– means after the proposer of the health insurance policy, ownership will be transferred to the nominee.

No Constructive Notice – any information of the policyholder or insured persons, that earlier not informed to the insurer

Non-Financial Transaction- means any transaction request by the policyholders does not affect the premium revision, like change of address, change of communication, correcting the insured person’s name spelling, etc.

Non- Medical Underwriting – means any risk evaluation not related to the medical condition like moral hazards, occupational hazards, or the financial status of the applicant in case of the super high sum insured

No Claim Bonus – means a reward of Sum Insured enhancement by the insurer if the previous year no claim, made by the insured person

O

OPD Treatment, Open Heart Replacement or Repair of Heart Valve, Open Chest CABG, Obesity Treatment, Obesity-related Cardiomyopathy, Other Renal Conditions, Opometic Therapy

OPD Treatment– Like regular medical treatment that does not require admission to a hospital, like cold, normal fever etc which does not involve any surgery, OPD treatment like this is not covered under normal health insurance, but this type of OPD The policyholder can reimburse all OPD treatments if hospitalization is required for 24 hours or more.

Open Heart Replacement or Repair of Heart Valve– Heart-related disease treatment/surgery.

Open Chest CABG– Heart-related disease treatment/surgery.

Obesity Treatment– means a person suffering from high BMI, and needs to go for Bariatric Surgery, but health insurance has some terms and conditions like other surgery, insured person’s BMI should be 40 and the age should be 18 years and for some exceptional cases it is done at BMI level 35 as well, but for the same, the conditions should be insured person should have suffers Obesity-related cardiomyopathy; Corona heart disease; Severe Sleep Apnea; Uncontrolled Type 2 Diabetes.

Obesity-related Cardiomyopathy– means weakness of heart muscle due to the heavy weight of the person.

Other Renewal Conditions– Renewal-related clauses.

Optometric Therapy- A type of special treatment that has a positive effect on eyesight and vision.

P

Portability, Permanent Paralysis of Limbs, Pre-Existing Diseases (PED), Pre-Hospitalization medical expenses, Post Hospitalization Medical Expenses, Parkinson’s Disease Resulting in permanent symptoms; Policy, Policy Periods, Policyholder, Policy Schedule, Policy Year, Pulmonary Artery Graft Surgery, Pneumonectomy Removal of an entire Lung, Prosthesis and Device, Possibility of RevisionnTerms of the Policy in including the premium rate, Premium Payment in instalments Prescribe Time Limit, Personal Accident Policy, Premium, Pre-Authorisation for Planned Treatment, Pre-Authorisation for Emergencies, Permanent Total Disability (PTD), Partial Permanent Disability (PPD), Policy Dispute, Product Benefits Table, Per Claim Deduction, Preferred Provider Network (PPN) Discount

Portability– transfer the health insurance policy into another company with continuity benefits and time-bound exclusions.

Permanent Paralysis of Limbs– means the treatment or surgery of the total loss of a leg or both due to injury or illness, after proper investigation and evaluation and certification by the specialist.

Pre-Existing Diseases (PED)– Even before taking the policy, the insured person is suffering from medical conditions/diseases and in health insurance, everyone has a waiting period like 24, 36 or 48 months, in some special cases depending upon the plan to plan PED waiting period waved off or in portability policies the PED time-bound period exclusion applied.

Pre-Hospitalization medical expenses– When an insured person incurs OPD expenses before being admitted to the hospital and is admitted to the hospital for treatment related to the same disease, this is covered in health insurance and is called Pre-Hospitalization medical expenses, plan to buy this OPD expenses of 30, 60 or 90 days are also covered.

Post-Hospitalization Medical Expenses– When an insured person incurs disease-related OPD expenses after discharge from the hospital, this OPD treatment is covered in health insurance and is called Post-Hospitalization medical expenses, from plan to plan it is 60, 90 or OPD expenses of 180 days are also covered.

Parkinson’s Disease Resulting in Permanent Symptoms– When a Neurologist doctor confirms Parkinson’s disease and gives this condition there must be Permanent clinical impairment of motor function with either associated tremor or muscle rigidity is covered in health insurance but “Parkinsonian syndromes/Parkinsonism” is not covered but once again, the policy wording of health insurance is to expand the clause. Where to see your insurance consultant.

Policy– means a health insurance policy

Policy Periods– the period between the commencement of risk cover start date and expiry date of the policy or either cancellation date whichever is earlier, the insured person will remain covered in the policy period.

Policyholder – one who owned the health insurance policy.

Policy Schedule– means a document issued by the insurer and its enclosed details of insured persons, proposer, Policy Period, limit sub-limits, benefits, any earned NCB, PED of insured persons, any amendment, any endorsement, policy premium and tax certificate.

Policy Year– pertaining to the policy years in which the insured person(s) cover

Pulmonary Artery Graft Surgery– means after advice by the cardiology, Pulmonary Artery Graft Surgery is covered by health insurance.

Pneumonectomy Removal of an entire Lung -means removal/surgery of the entire lung after the advice of a specialist medical practitioner.

Prosthesis and Device – means some of the medical devices that are covered in a health insurance policy, e.g. Multifocal Lenses; Cochlear Implant; Prosthesis- Leg, Arm, hand etc as mentioned in the policy wording.

Possibility of RevisionnTerms of the Policy in including the premium rate– This is the biggest question for the health insurance policyholder, that the premium keeps increasing every year on increasing age or changing the age slab and every insurance company gives reference to medical inflation or claim ration and increases the premium every 2-3 years. , which is given prior approval from IRDA

Premium Payment in instalments – The health insurance contract is for 365 days and the insurance company pays the premium for at least 365 days, so the applicant can pay the premium in instalments, for which the EMI option is available from lender finance, or credit card.

Prescribe Time Limit– means whatever the prescribed time limit to submit the IPD hospitalization reimbursement claim or post-hospital medical expenses, and it will be generally 30 days and 15 days respectively and will be depending upon the insurance company to the insurance company, the main reason to prevent fraud claim. and misrepresentation

Personal Accident Policy– a fixed benefits plan other than indemnity health insurance.

Premium– a premium or rate charged by the insurer to give cover for health insurance and it depends upon the applicant’s age, sum insured, family size past medical history and lifestyle habits

Pre-Authorisation for Planned Treatment– If any planned hospitalization is required, the insured person has to inform the insurance company within 72 hours that surgery/treatment is required.

Pre-Authorisation for Emergencies– means for any medical emergency the network hospital has to be informed within 24 hours, 1st health insurance company approves a pre-authorized treatment amount, on the discharge stage it will be increased or decreased depending upon the nature of treatment and cost as per the MOU sung between the insurance company and the hospital.

Permanent Total Disability (PTD)– means that a person becomes disabled as a result of injury or illness.

Partial Permanent Disability (PPD)– means partial permanent disability due to injury or illness, such as permanent loss of function of one leg, permanent loss of function of one eye, etc.

Policy Dispute – If any kind of dispute arises as per the terms and conditions mentioned in the policy boarding, its jurisdiction will be in India only.

Product Benefits Table– a table provided by the insurance company that mentions all the product benefit

Per Claim Deduction– when a policyholder opts for per claim deduction that means any event of hospitalization insured person will have to pay the bills as per the admissible claim, it will vary from plan to plan and insurance company to insurance company and will be 10K,20K, 50K etc.

Preferred Provider Network (PPN) Discount– This means that if you are hosted in a network hospital, you get to know the discount per claim and this is the option to choose, the policy applicant also gets to know the discount, and if the insured person goes to any hospital for treatment under PPN. How much co-payment also has to be paid

Q

Qualified Nurse– means any person who holds a valid registration certificate from the Nursing Council of India or any state nursing council of any Indian state.

R

Renewal, Room Rent, Room Types, Rest Care, Rehabilitation respite Care, Reconstruction, Refractive Error, RFQMR, Radiofrequency (RF), Road Ambulance Cover, Record to be maintained, Reimbursement Claim, Reduction in specific Diseases Waiting Period, Reduction in PED

Renewal – In health insurance, the contract is for 365 days, and the policy is renewed as per the mutual consent of the insured person and the insurer, the grace period in renewal is for 30 days, during which if any claim is made then it is not covered.

Room Rent– means the charges of the hospital for boarding and associated expenses,

Room Type– in health insurance room can be a single pvt AC room, Shared Room or Any Room.

Rest Care– means the observation care

Rehabilitation respite Care– means non-medical assistance to those, who are unable to perform their daily routine due to illness and mental illness

Reconstruction– means a process to repair/rebuild the body parts through the surgical process to improve the function of that particular body parts

Refractive Error– a kind of vision problem

RFQMR– (Rotational field quantum magnetic resonance ) is a device developed for tissue regeneration, and repair for the treatment of chronic diseases like Cancer, Arthritis etc.

Radiofrequency (RF)– is a kind of medical device that treats certain conditions.

Road Ambulance Cover– Road transport means road transport which takes an insured person to the nearest hospital in case of a medical emergency, is covered in health insurance on an actual basis or limits basis and it varies from plan to plan.

Record to be maintained– means a medical record with related documents

Reimbursement Claim– means a claim that does not get treatment at a Network hospital and the insured person files for reimbursement claim within the prescribed time limit by the insurer, or in case of pre-post medical expenses reimbursement claim can be filed by the insured person.

Reduction in specific Diseases’ Waiting Periods– in health insurance, there are many specific surgeries or procedures that cover after 24 months, the insured person can reduce this waiting period at an additional premium.

Reduction in PED– there is a waiting period applied for diseases that already have to the insured person like 24, 36 and 48 months, depending upon the plan, but in some insurers that insured person can reduce these types of waiting periods at the additional premium.

S

Surgery or Surgical Procedures, Surgical Treatment for Brain Tumor, Stroke Resulting in permanent symptoms, Surgery removal of an eyeball, Shared Room, Single Pvt AC Room, Second Medical Opinion for Major Illness, Sum Insured, Surgical Treatment of Coma, Skin Gratify Surgery for Major Burns, Surgery for Pheochromocytoma, Surgical Treatment for stroke, Sleep Anamia, Sterility and Infertility, Specific Exclusions, Stem Cell Therapy, Specific Treatment Exclusions, Specific benefits, Split Policy, Super Reload, Super Top Up,

Surgery or Surgical Procedures– means any type of surgical operation of a person for injury or illness.

Surgical Treatment for Brain Tumor– surgical procedures for the treatment of tumours related to the brain.

Stroke Resulting in permanent symptoms

Surgery removal of an eyeball– means surgical removal of a complete eyeball as a result of disease or injury, but in health insurance self-inflicted injury is not covered and the same has been certified by the specialist doctor.

Single Pvt AC Room– This is a hospital room that is meant for one patient and has air conditioning facilities but does not have an attached toilet.

Shared Room– means the most economical / cheapest room with more 2 or 3 or even more patient beds and without air conditioning.

Second Medical Opinion for Major Illness– On the request of the insured person, the insurance company, the treating doctor of the hospital suggests that the treatment procedure/surgery should be studied again as per the procedure of an independent medical practitioner, and if the insured person wants to do a physical consultation with a doctor himself.

Sum Insured– means the health cover amount, which is payable by the insurer as per the terms and conditions of the policy, including NCB, Super NCB, and Reload/Unlimited reloads.

Surgical Treatment of Coma– this means the surgical procedure for coma treatment.

Skin Gratify Surgery for Major Burns– in the health insurance context this surgery applies when 3rd degree burn on 20% of body parts and it should be not related to any type of cosmetic purpose.

Surgery for Pheochromocytoma –

Surgical Treatment for stroke– means surgery related to strokes. Diagnosis must be certified by a specialist medical practitioner and evidenced by the clinical symptoms and findings in CT Scan & MRI. In health insurance maybe there is very stringent terms and conditions as it is a very expensive treatment.

Sleep Apnea– A type of sleeping disorder that causes repeated interruptions in sleep, leading to daytime fatigue and is covered under health insurance when this condition is co-morbid with a major disease. Like sleep apnea is often seen in high BMI people.

Sterility and Infertility

Specific Exclusions – Claims for many things are not available in health insurance.

Stem Cell Therapy– means a medical treatment/procedures that repair or replace tissue to use the cell.

Specific Treatment Exclusions-In health insurance, there is a waiting period of 24 months for certain specific surgeries/treatments, which can be up to 3 or 4 years depending on the plan.

Specific benefits– if any insured person opted for any optional specific benefits

Split Policy– In health insurance, there is an age limit for providing cover to the dependent child as a family floater, after which the policy of the dependent child has to be separated with continuity benefits. These age limits are generally up to 25 years.

Super Reload– means the reload of sum insured additional to base, NBC & Super NCB that trigger up to base sum insured per hospitalization unlimited times during the policy period

Super Top Up– means a kind of indemnity health insurance plan that has some deductible like 5 lahks, 7 lahks, 10 lahks. These plans’ liability is covered by the insurer after deductible

T

Third Degree Burns, Treatment for alcoholism drug substances or any addictive condition, Treatment received in health hidrosanitare, Types of Claim, Total Temparirly Disablement (TTD)

Third Degree Burns – means the burn area covers at least 20% of the body and it should be clinically certified by the specialist medical practitioner.

Treatment for alcoholism drug substances or any addictive condition– when someone depends on the substances regularly that harm them and treatment related to these is not covered by health insurance.

Treatment received in health hidrosanitare– a kind of treatment that uses warm water.

Types of Claim– in health insurance, there will be multiple types of claims, IPD claim (Cashless & Reimbursement), Pre-Post Claim, TTD Claim, AD etc.

Total Temparirly Disablement (TTD)– in health insurance fixed benefits plan in Personal Accident policy, there’s a Benefits TTD, if any PA policyholder met with an accident and due to this he/she lost regular income due to bedrest, will get weekly payment from the insurer. The meaning of TTD is when someone is temporarily disabled for totally.

U

Unproven/Experimental Treatment, Utilisation of Sum Insured

Unproven/Experimental Treatment– unproven/experimental treatment expenses are not covered in health insurance, as per the insurer these are purposeless treatments.

Utilisation of Sum Insured– when insured person utilized their sum insured for treatment-related expenses.

w

Waiting Period, Withdrawal of Policy

Waiting Period- in health insurance, there are many types of waiting periods, e.g. PED waiting Periods, Initial Waiting Periods, Specific Surgery waiting periods, timebound specific waiting periods for Critical Illness

Withdrawal of Policy– If the health insurance company withdraws any plan in future, we will inform all the customers of our plan 90 days in advance, giving the policyholders the option to migrate to a similar plan in the same company with all the continuity benefits, subject to the break. not in policy.

Z

Zonal Premium – The insurer decides the premium in Urban, Semi-Urban and rural premium zones based on the demographics of hospitalization probability, claim history, and pollution condition, it varies from plan to plan and insurer to insurer.

Disclaimer: The above information is totally for educational purposes and his information does not constitute medical advice or diagnosis.