Health Insurance Glossary (1) - INDIA

Agent

An agent is appointed by the insurer to conduct business on behalf of the insurance company. An agent must hold a license issued by the IRDA.

Claim

The process of applying to the insurer for reimbursement of the expenses incurred for treatment is called “filing a claim”. Usually, this process is handled by a service provider to the health insurance company. This service provider is called a “Third Party Administrator” (See below).

Cashless Claim

As the term suggests, the insured can make a claim without paying any cash upfront.
The insurer or its Third Party Administrator have tie-ups with network of hospitals and nursing homes called a “network hospital”(see below) across the country. The insured can get themselves admitted in these specified network hospitals and take treatment for the disease contracted without any cash payment to the hospital at the time of discharge.
However cashless mediclaim settlement is subject to the limits and sub limits which is subject to the sum insured of the policy.

Coverage Amount

Coverage amount is the maximum amount payable in the event of a claim. It is also known as “sum insured” and “sum assured”. The premium of the health insurance policy is dependent on the coverage amount chosen by you.

Critical Illness Policy

A Critical Illness is a serious possibly terminal disease, which is strictly defined by the insurer. Conditions such as cancer, multiple sclerosis, major organ transplants are deemed as “Critical Illness”. Most critical illness policies provide for the payment of a lump sum benefit if the policyholder is diagnosed as suffering from one of a number of specified terminal conditions.

Cumulative Bonus

Each claim free year ensures that you get a benefit known as “cumulative”bonus – it is similar to “no claim discount”(see below) in concept. The only difference being that instead of giving an upfront discount, the health insurance company adds more benefits for the same premium paid. However, the overall amount of these benefits will not exceed a certain percentage as specified in the policy.