If you decide to purchase an insurance policy for health, you are presented with many of the offered documents. These documents contain crucial information about your coverage, as well as particular terms as well as conditions. It is essential to understand and read every one of these details to evaluate the quality and amount of financial protection offered.
But, some terminology used by health insurance companies can be challenging to grasp. If you aren’t aware of the policy’s specifics, you could commit serious errors. It is possible to end with diminished financial assistance in emergencies of medical nature.
If you know what these healthcare terms mean, will you be able to make a sound choice about choosing a health provider and coverage?
It’s essential to be an educated consumer before you approach your health insurance representative for the most appropriate healthcare insurance plan or quote. Learn the definitions of standard terms in health insurance terms in this glossary. It acts like a dictionary that can help customers comprehend the most common terms used in health insurance.
Standard Definitions of terminology to be used in Health Insurance Policies:
It has become increasingly necessary to ensure that specific basic terminology used in Health Insurance policies is given standard definitions so that prospects and insureds can understand them without ambiguity. All insurers shall adhere to the following standard definitions for the terminology listed hereunder. All insurance products filed hereafter fall under the definition of ‘Health Insurance Business’ wherever the said terms are referred to in the terms and conditions. Where a particular terminology does not apply to one or more types of policies, it is indicated against it in brackets.
1. Accident:
An accident is a sudden, unforeseen, and involuntary event caused by external, visible, and violent means.
2. Anyone illness: (not applicable for Travel and Personal Accident Insurance)
Anyone illness means a continuous period of illness. It includes relapse within 45 days from the date of the prior consultation with the Hospital/Nursing Home where treatment was taken.
3. Cashless facility:
A cashless facility is a facility extended by the Insurer to the insured.
The payments of the costs of treatment undergone by the insured by the policy terms and conditions are directly made to the network provider by the Insurer to the extent pre-authorization is approved.
4. Condition Precedent:
Condition Precedent means a policy term or condition upon which the Insurer’s liability under the policy is conditional.
5. Congenital Anomaly:
Congenital Anomaly is a condition present since birth and abnormal concerning form, structure, or position.
a) Internal Congenital Anomaly
Congenital Anomaly is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
Congenital Anomaly is a condition present since birth and abnormal concerning form, structure, or position.
6. Co-Payment:
Co-payment means a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible claim amount.
A co-payment does not reduce the Sum Insured.
7. Cumulative Bonus:
Cumulative Bonus means any increase or addition in the Sum Insured granted by the Insurer without an associated increase in premium.
8. Day Care Centre:
a) Internal Congenital Anomaly
Congenital Anomaly is not in the visible and accessible parts of the body.
b) External Congenital Anomaly
A congenital anomaly is in the visible and accessible parts of the body
A daycare centre means any institution established for daycare treatment of illness and injuries or a medical set up with a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criterion as under – i) has qualified nursing staff under its employment;
ii) has qualified medical practitioner/s in charge;
iii) has a fully equipped operation theatre of its own where surgical procedures are carried out;
iv) maintains daily records of patients and will make these accessible to the insurance company’s authorized personnel.
9. Day Care Treatment:
Daycare treatment means medical treatment and surgical procedure, which is:
- undertaken under General or Local Anesthesia in a hospital/daycare centre in less than 24 hrs because of technological advancement, and
- Which would have otherwise required Hospitalization of more than 24 hours.
Treatment generally taken on an outpatient basis is not included in the scope of this definition.
(Insurers may, in addition, restrict coverage to a specified list).
10. Deductible:
Deductible means a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the Insurer.
A deductible does not reduce the Sum Insured. (Insurers to define whether the deductible is applicable per year, per life, or event and the manner of applicability of the specific deductible)
11. Dental Treatment:
Dental treatment is related to teeth or structures supporting teeth, including examinations, fillings (where appropriate), crowns, extractions, and surgery.
12. Disclosure of information norm:
The policy shall be void, and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, misdescription, or non-disclosure of any material fact.
13. Domiciliary Hospitalization:
Domiciliary hospitalization means medical treatment for an illness/disease/injury that in the ordinary course would require care and treatment at a hospital but is taken while confined at home under any of the following circumstances:
i) the condition of the patient is such that they are not in a condition to be removed to a hospital, or
ii) the patient takes treatment at home because of the non-availability of room in a hospital.
14. Emergency Care:
Emergency care means the management of an illness or injury that results in sudden and unexpectedly symptoms and requires immediate care by a medical practitioner to prevent death or serious long-term impairment of the insured person’s health.
15. Grace Period:
Grace period means the specified period immediately following the premium due date. Payment can be made to renew or continue a policy without loss of continuity benefits such as waiting periods and coverage of pre-existing diseases. Coverage is not available for the period for which no premium is received.
16. Hospital (not applicable for Overseas Travel Insurance):
A hospital means any institution established for inpatient care and daycare treatment of illness and injuries and which has been registered as a hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act 2010 or under enactments specified under the Schedule of Section 56(1) and the said act Or complies with all minimum criteria as under:
i) has qualified nursing staff under its employment round the clock;
ii) has at least 10 inpatient beds in towns having a population of less than 10,00,000 and at least 15 inpatient beds in all other places;
iii) has qualified medical Practitioner (s) in charge round the clock;
iv) has a fully equipped operation theatre of its own where surgical procedures are carried out;
v) maintains daily records of patients and makes these accessible to the insurance company’s authorized personnel;
17. Hospitalization (not applicable for Overseas Travel Insurance):
Hospitalization means admission to a hospital for a minimum period of 24 consecutive
‘In-patient Care’ hours except for specified procedures/ treatments, where such admission could be for less than 24 straight hours.
18. Illness:
Illness means a sickness, disease, or pathological condition leading to the impairment of normal physiological function and requires medical treatment.
(a) Acute condition – Acute condition is a disease, illness, or injury that is likely to respond quickly to treatment that aims to return the person to their state of health immediately before suffering the disease/ illness/ injury, which leads to full recovery
(b) Chronic condition – A chronic condition is defined as a disease, illness, or an injury that has one or more of the following characteristics:
1. it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and tests
2. it needs ongoing or long-term control or relief of symptoms
3. it requires rehabilitation for the patient or for the patient to be especially trained to cope with it
4. it continues indefinitely
5. it recurs or is likely to recur
19. Injury:
Injury means accidental physical bodily harm, excluding illness or disease solely and directly caused by external, violent, visible, and evident means verified and certified by a Medical Practitioner.
20. Inpatient Care (not applicable for Overseas Travel Insurance):
Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
21. Intensive Care Unit:
An intensive care unit means an identified section, ward, or wing of a hospital that is under the constant supervision of a dedicated medical practitioner(s) and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
22. ICU Charges:
ICU (Intensive Care Unit) Charges means the amount charged by a Hospital towards
ICU expenses shall include the expenses for ICU bed, general medical support services provided to an ICU patient, including monitoring devices, critical care nursing and intensivist charges.
23. Maternity expenses:
Maternity expenses mean;
a) medical treatment expenses traceable to childbirth (including complicated deliveries and cesarean sections incurred during Hospitalization);
b) expenses towards lawful medical termination of pregnancy during the policy period.
24. Medical Advice:
Medical Advice means any consultation or advice from a Medical Practitioner, including issuing any prescription or follow-up prescription.
25. Medical Expenses:
Medical Expenses are those expenses that an Insured Person has necessarily incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured.
No more than other hospitals or doctors in the same locality would have been charged for the same medical treatment.
26. Medical Practitioner (not applicable for Overseas Travel Insurance):
A medical practitioner is a person who holds a valid registration from the Medical Council of any State or Medical Council of India or Council for Indian Medicine or Homeopathy is set up by the Government of India or a State Government and is thereby entitled to practice medicine within its jurisdiction and is acting within its scope and jurisdiction of license.
(Insurance companies may specify additional or restrictive criteria to the above, e.g., that the registered Practitioner should not be the insured or close member of the family. Insurance Companies may also specify definitions suitable to overseas jurisdictions where Indian policyholders are getting treatment outside India as per the terms and conditions of a health insurance policy issued in India)
27. Medically Necessary Treatment (not applicable for Overseas Travel Insurance):
Medically necessary treatment means any treatment, tests, medication, or stay in hospital or part of a stay in hospital which:
i) is required for the medical management of the illness or injury suffered by the insured;
ii) must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
iii) must have been prescribed by a medical practitioner;
iv) must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
28. Network Provider (not applicable for Overseas Travel Insurance):
Network Provider means hospitals or health care providers enlisted by an insurer, TPA or jointly by an Insurer and TPA to provide medical services to an insured by a cashless facility.
29. New Born Baby:
A newborn baby means a baby born during the Policy Period and is aged up to 90 days.
30. Non-Network Provider:
Non-Network means any hospital, daycare centre, or other providers not part of the network.
31. Notification of Claim:
Notification of claim means the process of intimating a claim to the Insurer or TPA through any of the recognized modes of communication.
When an insured person experiences a loss, damage, injury, or any other covered event that may qualify for insurance coverage, it is important to notify the insurance company promptly.
This notification initiates the claims process and allows the insurance company to assess the claim, gather necessary information, and determine coverage eligibility.
The notification of claim typically involves contacting the insurance company’s designated claims department or representative. The insured person or their authorized representative must provide details about the incident or event, including the date, time, location, and a description of what occurred. Depending on the type of claim, supporting documentation such as photographs, police reports, medical records, or repair estimates may also be required.
32. OPD treatment:
OPD treatment means the one in which the Insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as daycare or inpatient.
33. Pre-Existing Disease (not applicable for Overseas Travel Insurance):
Pre-Existing Disease means any condition, ailment or injury, or related condition(s) for which there were signs or symptoms and were diagnosed, and for which medical advice/treatment was received within 48 months before the first policy issued by the Insurer and renewed continuously after that.
(Life Insurers may define norms for applicability of PED at reinstatement).
34. Pre-hospitalization Medical Expenses
Pre-hospitalization Medical Expenses means medical expenses incurred during a predefined number of days preceding the Hospitalization of the Insured Person, provided that:
i. Such Medical Expenses are incurred for the same condition for which the
An Insured Person’s Hospitalization was required, and
ii. The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.
35. Post-hospitalization Medical Expenses:
Post-hospitalization Medical Expenses means medical expenses incurred during a predefined number of days immediately after the insured person is discharged from the hospital, provided that:
i. Such Medical Expenses are for the same condition for which the insured person’s Hospitalization was required, and
ii. The inpatient hospitalization claim for such Hospitalization is admissible by the insurance company.
36. Qualified Nurse (not applicable for Overseas Travel Insurance):
A qualified nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India.
Qualified nurses play a vital role in the healthcare system, assisting physicians and other healthcare professionals in delivering comprehensive care to patients.
They are trained in various aspects of healthcare, including administering medications, monitoring patient vital signs, performing medical procedures, assisting with patient examinations, providing wound care, and offering emotional support to patients and their families.
37. Reasonable and Customary Charges (not applicable for Overseas Travel Insurance)
Reasonable and Customary charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness/injury involved.
38. Renewal:
Renewal means the terms on which the insurance contract can be renewed on mutual consent with a provision of grace period for treating the renewal continuous to gain credit for pre-existing diseases, time-bound exclusions, and all waiting periods.
39. Room Rent:
Room Rent means the amount a hospital charges towards Room and Boarding expenses and shall include the associated medical expenses.
When a person requires hospitalization, they are assigned a room where they receive medical care and stay for the duration of their treatment or recovery. The room rent coverage provided by health insurance plans typically includes the charges for the room, which may vary depending on factors such as the type of room (general ward, semi-private, or private room) and the hospital’s location.
The insurance policy specifies the maximum limit or percentage of the room rent that will be covered by the insurance company, and any expenses exceeding that limit will be the responsibility of the insured person.
It’s important to review the terms and conditions of your health insurance policy to understand the extent of room rent coverage provided.
40. Subrogation (Applicable to other than Health Policies and health sections of Travel and PA policies):
Subrogation means the Insurer’s right to assume the insured person’s rights to recover expenses paid out under the policy that may be recovered from any other source.
41. Surgery or Surgical Procedure:
Surgery or Surgical Procedure means manual and operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief from suffering and prolongation of life, performed in a hospital or daycare centre by a medical practitioner.
It typically involves making incisions or using minimally invasive techniques to access the affected area of the body.
Surgeries are performed by trained surgeons or surgical teams in a sterile environment such as an operating room. Surgical procedures can vary widely depending on the specific medical condition being addressed, ranging from minor procedures performed under local anesthesia to major operations requiring general anesthesia.
Surgeries can be therapeutic, aiming to remove, repair, or modify diseased or injured tissue, or diagnostic, aiming to investigate and determine the cause of a medical problem.
42. Unproven/Experimental treatment:
Unproven/Experimental treatment means the treatment, including experimental drug therapy, which is not based on established medical practice in India, is the treatment experimental or unproven.
Unproven/Experimental treatment refers to a type of treatment or therapy that has not been established or proven to be effective through scientific research and medical practice. It involves using medical interventions, including experimental drug therapies, that have not yet gained widespread acceptance or approval within the medical community.
In the context of health insurance, coverage for unproven/experimental treatments may be limited or excluded, as insurance companies typically prioritize coverage for treatments that have been extensively studied and shown to be safe and effective.
The determination of whether a treatment is considered unproven or experimental is often made by medical professionals and regulatory bodies based on available evidence and clinical trials.
Source: – IRDAI website
