Health Insurance Glossary

health insurance terminologies

Health insurance can be confusing. Between the many policy options, riders, and premiums, it can be difficult to understand what you’re buying. This Health Insurance Glossary will help make sense of some of the most commonly used terms in health insurance. By understanding these terms, you’ll be able to make more informed decisions about your health coverage.

Glossary of Health Insurance in India: Terminologies Explained (A to Z Definitions)

List of Basic Glossary Terms and Terminologies Used in Health Insurance:

A

Age Limit:The minimum age at which a person can apply for or renew a health insurance policy.

Agents: Individuals who serve as a liaison between the insurance company and the customers. They assist customers in understanding the features and benefits of a plan, as well as renewing the policy or filing a claim against it.

Accident: An unforeseeable, unexpected, and uncontrollable event that causes financial loss to the policyholder.

Annual Renewal Date: The date by which the policyholder’s health insurance policy must be renewed.

Any One Illness: A period of continuous illness that recurs within 45 days of the last date of consultation with the respective hospital or nursing home.

AYUSH Treatment: Ayurveda, Yoga, Unani, Siddha, and Homeopathy are the full forms of AYUSH (referred to as alternative medicine treatment). Such treatments are covered by some health insurance policies.

Ambulance coverage: Coverage for ambulance transportation to the hospital.

Accumulation Period: The time period during which any medical expenses incurred by the policyholder are applied to the applicable health insurance deductible. Only after the deductible has been met will the insurer begin to cover the policyholder’s and beneficiaries’ medical expenses.

Add-on Covers: Add-ons are small packages that supplement the standard policy’s coverage for a slightly higher premium. They provide additional financial protection against certain high-cost medical treatments. Some add-ons offer exclusive coverage for maternity, critical illness, hospital cash benefit, and so on.

Automatic Restoration: Some policies offer the option of restoring the sum insured if it has been depleted. It is restored automatically for the next hospitalization.

B

Benefit: A ‘Benefit’ is any benefit stated in the Policy Schedule or Certificate of Insurance.

Beneficiary: A beneficiary is the policyholder and the person named in the Certificate of Insurance who receives policy benefits in the event of the death of the primary policyholder or a policyholder who receives policy benefits.

Bodily Injury: A physical injury to the beneficiary’s body, such as cuts, bruises, abrasions, and so on.

Broker: The person or company who serves as the intermediary between the insurer and the policyholder. A broker, unlike an agent, is not employed by the insurer.

C

Cashless Facility/Hospitalization: A service provided by the insurer to the insured in which the insurer pays the medical bills directly to the network provider or hospital.

Claim: A formal request by the insured to the insurance company for payment or compensation of medical costs based on the insurance policy’s benefits.

Claim Settlement: The process by which the insurer pays for the medical bills that the policyholder has claimed. Claims can be resolved using either the cashless claims process or the reimbursement process.

Claim Settlement Ratio: A metric that compares an insurance company’s ability to settle health insurance claims to the number of health insurance claims received over the course of a fiscal year. It also includes any previous year’s pending claims.

Co-Pay or Co-Payment: A cost-sharing agreement between the insurance company and the policyholder is referred to as a co-pay or co-payment. It states that the policyholder will be responsible for a portion of the claim amount.

Comorbidities/Pre-Existing Diseases: Comorbidities occur when two or more illnesses or diseases coexist in a patient, or when additional conditions or diseases frequently co-occur with a primary condition.

Critical Illness: A critical illness, disease, or sickness is one that is life-threatening. Critical illnesses include kidney failure, cancer, a heart attack, bypass surgery, and so on. Some insurers offer critical illness add-ons in addition to standard health insurance plans.

Cashless Claims/Treatment: An easy and paperless way to pay medical bills to a network hospital. The insurer will deal directly with the hospital or third-party administrator to settle the claim or medical bills. This claim procedure is known as cashless claims because the policyholder is not required to pay the bill unless specified in the terms and conditions.

Cumulative Bonus: Refers to the bonus given to the policyholder by the insurer for not filing a claim during the policy period. The bonus can range from 5% to 10% of the sum insured and can reach up to 50% of the sum insured.

Coverage Period: The coverage period is the time between the start date and the expiration date of the insurance policy during which the policyholder is eligible for the benefits of the insurance plan.

Convalescence Benefit: A cash benefit paid to the policyholder during his or her hospital stay. This is provided in the event that the patient must remain in the hospital for an extended period of time. It is provided in the form of a pre-defined lump-sum payment in the policy schedule.

D

Deductible: A set amount that the policyholder must pay each year in order to file a claim under the policy. For example, if the deductible is Rs. 20,000, the insurer will cover your medical expenses after you pay the first Rs. 20,000 in medical bills.

Dependents: Any family members for whom the policyholder is willing to assume medical coverage are considered dependents. Dependents include the spouse, children, and parents/in-law.

Daily Hospital Cash: A benefit provided by some insurance policies that provides the policyholder with a fixed cash payment for each day of hospitalization. It is a cash benefit for meeting additional expenses not covered by health insurance or for compensating for lost income while hospitalized. It is available as an add-on or as part of the standard plan.

Domiciliary Hospitalization: Domiciliary hospitalization refers to medical treatment received by the policyholder at their home.

E

Eligibility refers to the conditions or criteria that a person must meet in order to apply for a health insurance policy.

Exclusions: An exclusion from policy coverage is any condition, illness, disease, or sickness that the insurance policy does not cover. Before selecting the right plan, it is critical to review the list of exclusions.

Emergency Care: Any hospitalization required due to an unexpected or sudden emergency is classified as emergency care.

F

First Diagnosis The first recorded medical diagnosis of an illness, disease, or condition is referred to as the “First Diagnosis.”

Family Floater Policies: A Family Floater Policy is a single health insurance policy that covers more than one beneficiary. It typically covers the policyholder and their dependents, which may include their spouse, children, and parents/parents-in-law.

Free Look Perio: A free look period is a period of time during which a policyholder can cancel the policy without penalty. Insurance companies offer this feature without penalty, and the period can last up to 15 days.

G

Grace Period: A special or extended period after the due date to pay the plan’s renewal premium. There is no health insurance coverage during this time until the policy is renewed; however, the existing policy benefits remain in effect. The grace period is usually between 15 and 30 days.

H

Hospitalization is defined as admission to a hospital for at least 24 hours. This criterion applies to both planned and unexpected hospitalization.

Home Nursing: A nursing specialty in which nurses provide home care to patients who have received hospital treatment. The services are provided based on the medical practitioner’s and specialist’s recommendations.

I

Illness: A sickness or a pathological condition or disease that disrupts normal physiological functions and necessitates medical treatment.

  • Acute Illness or Injury: An illness or injury that responds quickly to treatment and results in full recovery.
  • A chronic condition is defined as a disease, illness, or injury that requires long-term or ongoing treatment, symptom relief, rehabilitation, or is recurring.

Insurer: The insurance company that provides financial assistance for the policyholder’s and beneficiaries’ medical treatment.

Insured/Insured Person: The insured or the insured person is the beneficiary of the insurance policy and/or the dependent family members named in the policy schedule.

In-Patient Treatment: A treatment that necessitates the patient being hospitalized for at least 24 hours for a treatment covered by the policy.

ICU Charge or Room Rent: The charge for the policyholder’s or beneficiary’s use of the Intensive Care Unit room.

Individual Health Insurance: A policy that covers a single person for both planned and unplanned hospitalization.

IRDAI: The full form of IRDAI is the Insurance Regulatory and Development Authority of India, which is the apex body or the regulator of the insurance sector or industry in India.

L

Lapse occurs when an insurance policy terminates or expires due to a lack of premium payment.

Long-Term Care Policy: A long-term policy is one that covers specific treatment for a set period of time, such as nursing care, home nursing, and custodial care.

M

Maternity Cover: The insured can receive financial assistance for medical expenses incurred during childbirth. It covers medical expenses for childbirth (both normal and cesarean), pre- and post-natal care, and so on.

N

Network Provider/Hospital: A hospital, nursing home, or healthcare provider that has been approved by the insurance company to provide medical treatment to the insured through a cashless facility or hospitalization.

Non-Network Provider/Hospital: A hospital, nursing home, or healthcare provider that is not listed by the insurance company or that is not part of the insurer’s hospital network.

Nominee: A person designated by the primary policyholder to receive policy benefits in accordance with the policy’s terms and conditions.

No Claim Bonus (NCB): The NCB is a benefit or discount given to the policyholder by the insurance company for not filing any claims during the period. This bonus comes in the form of a larger sum insured for the same premium.

O

Out-Patient Department (OPD)/Treatment: Out-patient treatment is defined as any treatment that takes less than 24 hours and does not require hospitalization. The person receiving treatment is referred to as an out-patient, and the department providing the service is referred to as the out-patient department, or OPD.

P

Primary Insured: The primary insured is the person who applies for the insurance policy and pays the premium for the coverage.

Policy Period: The time period between the start date and the expiration date of an insurance policy is referred to as the policy period.

Premium: The amount paid to the insurance company by the policyholder in order to obtain health insurance coverage. The premium is typically paid on an annual basis.

Pre and Post-Hospitalization Expenses: Pre and post-hospitalization expenses are medical expenses incurred prior to and following the insured person’s hospitalization.

Portability: The primary insured is the person who applies for the insurance policy and pays the premium for the coverage.

Policy Period: The time period between the start date and the expiration date of an insurance policy is referred to as the policy period.

Private Room: The amount paid to the insurance company by the policyholder in order to obtain health insurance coverage. The premium is typically paid on an annual basis.

Pre and Post-Hospitalization Expenses: Pre and post-hospitalization expenses are medical expenses incurred prior to and following the insured person’s hospitalization.

R

Renewal: The act of renewing a health insurance policy for another period by paying the required premium on or before the renewal date.

Reimbursement: If a policyholder receives medical treatment at a non-network hospital, they can recover their medical expenses by requesting reimbursement from the insurance company. The process by which the insurer settles claims is known as reimbursement claims.

Restoration Benefit: If the sum insured is depleted, the insurer will recharge or re-fill the sum insured through the benefit.

Room Rent: A fee paid for the use of a hospital or nursing home room. In most cases, the policy schedule specifies a ceiling for room rent.

S

Sum Insured: The maximum amount payable under the insurance policy. The policyholder cannot make a claim in excess of the sum insured. The policy premium is calculated based on the sum insured.

Survival Period: The amount of time that a policyholder or beneficiary of an insurance policy should live after being diagnosed with a covered sickness, condition, or illness.

Sub-Limit: A sub-limit is a limit set by the insurance company for specific medical care. Such illnesses cannot be treated beyond the specified sub-limit. Room rent, doctor’s consultation fees, ambulance charges, and pre-planned medical treatments such as cataract surgery, plastic surgery, and so on are commonly subject to sub-limits.

T

Third-Party Administrator (TPA): TPAs are those who have been authorized by the insurance provider to provide administrative services to customers or policyholders. Their primary responsibility is to process claims, settle claims, collect premiums, and so on.

Terminal Illness: Terminal illnesses are illnesses, conditions, or diseases that cannot be treated or cured. Some examples include heart problems, advanced cancer, and so on.

Top-up Plans: These are plans that can be purchased in addition to the standard health insurance policy. When the standard plan’s sum insured is depleted, the top-up plan will cover the medical expenses.

W

Waiting Period: The period during which the insured will not be able to use some of the policy’s benefits. Typically, this fixed period begins on the policy’s start date. When the policy expires, the insured can claim the benefits. Depending on the type of insurance policy, pre-existing diseases, conditions, or illnesses may have a waiting period of up to four years.

Group Health Insurance Policy Terminologies

Mentioned below are terminologies associated with the Group Health Insurance Policy.

GMC

It’s an abbreviation for Group Medical Coverage, which is another name for group health insurance, corporate health insurance, or employee health insurance.

Group

A group is a group of people who are covered by a single health insurance plan. In Group Health Insurance, a group can be either employer-employee or non-employer-employee. Cultural or social organizations can also be classified as groups for the purposes of applying for the GMC.

Coverage

It refers to the provisions specified in the insurance policy to cover the policyholder’s or group’s liabilities.

Master Policyholder

The manager/leader/representative of the group who receives the Certificate of Insurance.

Eligibility Date

Refers to the date on which a group member begins to receive Group Medical Coverage.

Effective Date

Refers to the date from which the policy becomes active and the insured can start enjoying the benefits of the policy.

Employee

A salaried or waged employee who is typically a full-time employee and may be eligible for Group Health Insurance.

Conclusion

We hope that this Health Insurance Glossary has been helpful in understanding the terminology and concepts used in health insurance. If you have any questions, please don’t hesitate to reach out to us for more information or clarification.

Similar Posts

Leave a Reply

Your email address will not be published.