Health Claims Information

A health insurance or mediclaim policy is a basic health indemnity cover that protects you and your family from unplanned hospitalisation expenses. To buy a health insurance online, just enter your basic details like age, gender, amount of coverage required and type of plan (individual or family floater) and get quotes from different insurance companies instantly. Compare and Select the quote that best suits your requirement, fill up the proposal form and make payment to get insured.

A health insurance or a mediclaim policy is an insurance contract which covers the medical expensesincurred by an individual in case of hospitalisation. The policy covers the financial implications incurred at the time of medical contingencies and pays either the actual medical expensesincurred or a lump sum benefit depending on the plan’s coverage features
A Health Insurance policy is not a financial priority anymore, it has become a necessity in today’s age due to the continuous rise in healthcare risks and prices inflation. Any unplanned hospitalisation would lead to numerous expenses such as medicinal treatment or surgery costs, diagnostics test charges, pharmacy, doctor’s visits, room rents,ambulance transportation charges etc. These costs can easily cripple a family’s financial health in a flash.But with the right health insurance cover, you can protect yourself and your family from these medical expenses without causing much dent in your savings. Do not let the massive costs oftreatment become a hindrance inseeking the right care for a loved one. Get a health insurance for your family now.
Following are some of the key coverages and benefits you get when you buy a health insurance policy:

1. Cost of hospitalization:All the hospitalization expenses incurred due to illness oraccident injuries

2. Pre and posthospitalization expenses: Expenses incurred during a certain number of days before and after hospitalization as long as they are related to the illness/injury

3. Day care procedures: Surgeries and treatments that do not require 24- hour hospitalisation,due to technological advancements, are also covered

4. Ambulance cover: Transportation of the patient to hospital

5. Income Tax benefit: Save upto Rs 75,000 on tax (25,000 for self and family & additional 50,000 if senior citizen parents included) under section 80(D) of Income Tax Act

6. Organ donor expense: Medical expenses of organ donor during an organ transplant.

7. No Claim Bonus: Bonus given to the insured during renewal in case of no claims are filed in the previous policy year. The bonus can be in the form of an increase in the sum insured.

8. Cashless treatment: Can be availed when hospitalised in one of the network hospitals of insurance company

9. Sum insured recharge: Sum insured gets replenished on exhaustion of entire health cover

10. Alternative treatments (AYUSH Benefit): Alternate therapies like Ayurveda, Unaani, Siddha and Homeopathyget covered

11. Free health check-ups: Free health check-up facility given to the insured members upto pre -defined limit in policy.

12. Domiciliary hospitalization (Health homecare): Treatments availed at home on doctor’s recommendation

13. Convalescence Benefit: Lumpsum amount given to the insured person as a recovery benefit in case of a long duration of hospitalisation

It is important to realize that inclusions will vary from one provider to the next and from plan to plan.
Some of the exclusions under a health insurance policy are as follows:

1. Expenses due to pre-existing disease incurred during waiting period

2. Expenses occurred during the waiting period for the disease/ailments having mandatory waiting period

3. Cosmetic and Dental surgery expenses

4. Sexually transmitted diseases

5. Self-inflicted injuriesor adventure sports

6. Injuries caused due to war

Detailed list of exclusions can be found in the policy wordings of the respective health insurance product.
There are two types of health insurance plans available today. They are as follows:

1. Individual health insurance plan: This type of plan suits for individuals who chose to buy a policy for covering one individual.

2. Family health insurance plan: This type of plan provides coverage for the entire family which can include spouse, parents and children. The sum insured can be shared among all the family members or each family member can have an individual sum insured.

Choosing the right health insurance plan is the most important step while purchasing a policy. Following are some of the factors that should be kept in mind while looking for a health insurance:

1. Sum insured: Determining the right coverage is the first step when opting to buy a health insurance. Individuals residing in metro cities may go for higher sum insured. If looking for family health insurance plans, sum insured above 10 lacs can be considered so as to cover multiple claims in a year from different members without exhaustion

2. Sub-limits: Policies that do not have sub-limits on room rents i.e. no higher limit on the rent charges are always recommended.

3. Co-payment: Policies that have co-payment option have lesser annual premiums because the insured individual pays a fraction of the hospital expenses and the rest is borne by the insurance company. Though the premiums are discounted but the co-payment amount could be a significant amount in case of high value claims.

4. Waiting period: Some insurers have shorter waiting periods for pre-existing ailments. Specific covers like maternity benefits are covered after 3 years under policies of few insurance companies. The shorter the waiting period, the better for the insured person.

5. Cashless hospital network: Insurance companies have tie-ups with hospitals across the country. One should always look for the insurer who has more number of hospitals under their cashless service.

There are numerous health insurance plans available in the market. Each plan has its own inclusions and exclusions list, benefits and features, cashless hospital network, sub limits, waiting periods for certain illnesses etc. Hence it becomes imperative to compare these plans first and then choose the one which suits your requirements the most. Policy anchor helps you choose the right plan by showing a detailed comparison of all the health insurance policies available based on the data provided and hence assists you in making an informed choice.
You can compare and buy health insurance online in a few easy steps. Visit Policy anchor website and select health insurance. Then you will be asked to enter few basic details like age, sum insured amount, area of residence, number of members to be insured etc. Based on the details submitted, quotes from various health insurance companies will be displayed. You can select multiple plans and compare the benefits and coverages provided along with the premium. After you have decided on a particular policy that fulfils your requirements, you can select the plan and proceed to the proposal form stage. You have to provide accurate and correct information in the proposal form. After the form is filled, you can review all thedetails shared till now in the summary page. After reviewing, you can proceed to make the payment online through various modes like credit/debit cards, internet banking, wallets etc. Post successful payment, health insurance policy will be generated and emailed to you instantly.
Pre-existing disease is a disease or a condition existing in a person before he purchases the policy. The individual buying a health insurance policy should declare all such known diseases in the proposal form. The insurance company may verify medical test reports and agree to cover such pre-existing diseases after a certain waiting period.
Yes, but after a certain waiting period as specified in the policy wordings. The waiting period can range from 2 to 4 years depending on the underwriting policy of the insurer. Also, the insured member should declare his medical history accurately in order to claim any expense arising out of the treatment for such diseases, else the claim might get rejected.
  • Any illness/ disease/ injury/ pre-existing disease before the inception of the policy. However, this exclusion ceases to apply once the waiting period is over
  • Non-allopathic treatment, pregnancy and childbirth related complications, cosmetic, aesthetic and obesity related treatment
  • Expenses arising from HIV or AIDS and related diseases, use or misuse of liquor, intoxicating substances or drugs as well as intentional self-injury
  • War, riots, strike, nuclear weapon, induced treatment
No, there is a waiting period of 30 days from the day of inception of the policy. Any treatment of illness undergone during this period is not covered in the policy except for injuries from accidents.
Before an individual is hospitalized, there are preliminary expenses which are incurred on doctor’s consultations for diagnosing the illness, medical tests for finding out the reason for illness, medicines, etc. These expenses are called pre-hospitalisation expenses. Similarly there might be treatment costs incurred after the individual is discharged from the hospital. These are called post hospitalisation expense. Both pre and post hospitalisation charges upto a certain number of days are covered in most health insurance plans, provided the hospitalisation expenses claim is covered by the insurer.
If the sum insured is exhausted in the treatment of a member, no further claims would be paid by the health insurance policy in that policy year. If another claim occurs within the same policy year, it would be denied. But from the next policy year, the full sum insured would be available for subsequent claims. In case Sum Insured Recharge benefit is opted while purchasing the policy, then the sum insured will get replenished upon exhaustion in the same policy year however it can only be availed for a different treatment.
A health insurance portability is a provision given by IRDA that allows the insured to switch their health insurance policy to a different insurer while retaining all the accumulated benefits from the old insurer like waiting period, no claim bonus, etc. In order to avail this facility, the policyholder will have to intimate the new insurer where he/she wishes to port at least 45 days prior to the policy renewal date.
The premium in a health insurance policy is the amount of money which you pay to the insurance company to buy the health coverage. The premium depends on a number of factors that the proposer declare at the time of buying insurance.
The premium for health insurance is calculated based on a number of factors. Some of them are listed below:

1. Age: One of the most important factor that decides your health insurance premium. The older you get, the more you have to pay for insurance as the probability of getting illis high.

2. Number of members to be covered: Depending on the number of members you want to include in your policy, the premium is calculated. For a family of four including children, the premium will be high whereas for insuring an individual, premium would be low.

3. Pre-existing ailments: Premium will be high for individuals who have a history of illness e.g. diabetes, hypertension etc.

4. Location of residence: Depending on the place you live, the premiums vary. Cost of treatments in metro and tier-1 cities are high, hence premium is high for individuals residing in such locations. Whereas tier 2 and tier 3 cities will have lesser premium for the same individual.

5. BMI: Your body mass index also plays a role in deciding your health insurance premium. Individuals with high BMI will have to pay more for insurance cover as they are assumed to be more prone to serious ailments. If you have a BMI in healthy range, the premium would be lesser.

You can pay premium online through one of the various modes of payment offered by insurance companies. Once you have shortlisted a health insurance plan and filled the proposal form, you will be redirected to the payment page of the insurance company. You can then choose to pay through credit or debit cards, net banking, wallets or UPI. Some insurance companies also provide EMI facility on select credit cards.
Premium up to Rs.75,000(Rs. 25,000 for self and family & additional Rs. 50,000 if senior citizen parents included) can be claimed for income tax deduction under Section 80(D) of the Income Tax Act.
Yes, you would be required to pay premium again. However you can avail the benefit of No Claim Bonus if it is being offered by your insurance company. Through this benefit, you sum insured amount may get enhanced further by a fixed amount for every claim free year.
Yes you can cancel your health insurance and get your premiums refunded. Every health insurance policy has a freelook up period of certain number of days. If you are not satisfied by terms of the health insurance policy purchased, you may apply for cancellation. In such cases the insurance company will refund your premium amount after some deductions made for processing costs incurred by them. In case of cancellation after freelook period a pro-rated amount will be deducted.
A claim is defined as the demand made on the insurance company to compensate for the financial losses suffered by the policyholder when the insured event occurs. A health insurance claim occurs when the insured suffers a medical contingency and demands compensation formedical costs which are covered under the policy.
Cashless claim settlement is a processwhere the insurance company takes care of the medical bills itself without you having to pay for the medical cost yourself. A cashless claim is allowed only when you get admitted to a hospital which is tied-up with the insurance company. In such cases, the insurance company settles your medical bills directly with the hospital and you don’t have to bear the financial burden of your medical emergency.
In a cashless health insurance policy your medical costs are handled directly by the insurance company. They are paid by the insurance company to the hospital and you can avail treatments without having to bear the financial burden. As such, a cashless health insurance policy provides you financial relief in medical emergencies. Moreover, since your medical bills are met by the insurance company, you don’t have to draw on your savings to pay for hospitalisation. You can also avail quality healthcare when you know that the subsequent costs would be borne by the insurance company and not you.
Claim assistance is the help offered at the time of a health insurance claim. Insurance companies have a dedicated claim assistance team to help their policyholders with their health insurance claims. They guide the policyholders with the required steps to be followed in order to get their claims settled. Policy anchor also provides claim assistance services to its customers. In case of a claim under your health insurance policy you can contact Policy anchor at our toll-free number +91 8860005761 or drop us an email at Our claim experts will help you get your health insurance claims settled at the earliest.
Claim can be of two types:
Where the member of the covered family is aware of the hospitalisation 2-3 days in advance. In case of planned hospitalisation:
  • Please contact your Service provider or TPA help-line mentioned in the Health Identity Card
  • Fax / submit the required documents. E.g. Doctor's certificate, medical bills etc.
  • Obtain approval from the Service Provider or TPA
Where the insured meets with sudden accident or suffers from bout of illness that requires immediate admission to the hospital. In case of emergency hospitalisation:
  • The patient is to be rushed to the hospital
  • Patient avails treatment
  • Family/Friends/Employer to contact Service Provider or TPA help-line as mentioned in the Health Identity Card
Cashless claim facility can only be availed at network hospitals. For non-network hospitals, claims can be availed in form of reimbursement upon submission of relevant bills.
The following are basic documents required for filing a claim:
  • Duly completed claim form
  • Original bills, receipts and discharge certificate/ card from the hospital
  • Original bills from pharmacy supported by proper prescription
  • Receipt and investigation test reports from a pathologist supported by the note from attending Medical practitioner / surgeon prescribing the test.
  • Nature of operation performed and surgeon's bill and receipt.
Cashless hospitalization is a facility provided by the insurers wherein the insured can get admitted and undergo the required treatment without paying directly for the medical expenditure. The medical expense, thus incurred, shall be settled by the company directly with the hospital. The Cashless claim facility can be obtained only at the hospital network the service provider has a tie-up with.
In case of a reimbursement claim, the insured pays the expenses himself with the hospital and then claims for a reimbursement of those expenses.
Pre-authorization is basically an authorization issued either by the insurance company or the service provider, specifying the value of the medical treatment that can be claimable under their insurance policy. To receive a pre-authorization, you need to submit duly fill in the Pre-authorization form.
  • Network Hospitals: The company ties up with hospitals for cashless claim process. When you avail of a cashless treatment in any of these network hospitals, the company would settle the claim with the hospital directly. For a complete list of network hospitals, log on to Service Provider's or TPA's website. Hospital network list of each Service Provider or TPA may vary.
  • Non-network Hospitals: Non network hospitals are the ones with which the company does not have a cashless tie up. When you avail treatment here, you first settle the bills yourself and then submit the relevant documents and bills to the service provider or TPA. The amount, consequently, is reimbursed to you based on policy terms and conditions.
Cashless hospitalization is available only in network hospitals. You are at liberty to choose a non-network hospital also. The non-network hospital should be compliant with hospital facility definition and geographical limits as defined in policy documents. In case you avail treatment in a non-network hospital, insurer will reimburse you the amount of bills subject to the policy taken by the policyholder. Note: Only expenses relating to hospitalization will be reimbursed as per the policy taken. All non-medical expenses will not be reimbursed.