1 Standard Definitions of Terminology used in Health Insurance Policies PUBLISHED IN THE GUIDELINES ON STANDARDISATION IN HEALTH INSURANCE VIDE IRDA CIRCULAR NO: IRDA/HLT/CIR/036/02/2013 DATED Accident An accident is a sudden, unforeseen and involuntary event caused by external and visible means. [Insurance companies can define the term accidental injury in the context o f the term 'accident']. 2. Co-Payment A co-payment is a cost-sharing requirement under a health insurance policy that provides that the policyholder/insured will bear a specified percentage of the admissible costs. A co-payment does not reduce the sum insured. 3. Day Care Treatment Day care treatment refers to medical treatment, and/or surgical procedure which are: i. Undertaken under General or Local Anesthesia in a hospital/day care Centre in less than 24 hrs. because of technological advancement, and ii. Which would have otherwise required a hospitalization of more than 24 hours Treatment normally taken on an out-patient basis is not included in the scope of this definition. [Insurers may, in addition, restrict coverage to a specified list]. 4. Deductible A deductible is a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee amount of the covered expenses, 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 whether per event and specific deductible limits would be applied] 5. Dependent Child A dependent child refers to a child (natural or legally adopted), who is financially dependent on the primary insured or proposer and does not have his / her independent sources of income. [Insurers can add additional criteria relating to age, marital status, education and disablement]. 6. Domiciliary Hospitalization Domiciliary hospitalization means medical treatment for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances: i. The condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
2 ii. The patient takes treatment at home on account of non availability of room in a hospital. 7. Emergency Care Emergency care means management for a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the insured person s health. 8. Grace Period Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force 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. 9. Hospital A hospital means any institution established for in-patient care and day care treatment of sickness and / or injuries and which has been registered as a hospital with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under: Has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and 15 inpatient beds in all other places; Has qualified nursing staff under its employment round the clock; Has qualified medical practitioner (s) in charge round the clock; Has a fully equipped operation theatre of its own where surgical procedures are Carried out. Maintains daily records of patients and will make these accessible to the Insurance Company s authorized personnel. 10. Intensive Care Unit Intensive care unit means an identified section, ward or wing of a hospital which 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. 11. Inpatient Care Inpatient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event. 12. Medical Practitioner A Medical practitioner is a person who holds a valid registration from the medical council of any state of India and is thereby entitled to practice medicine within its jurisdiction; and is acting within the scope and jurisdiction of his license. [Insurance companies can specify additional or restrictive criteria to the above, e.g. that the registered practitioner should not be the insured or close family members].
3 13. Medically Necessary Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which - is required for the medical management of the illness or injury suffered by the insured; Must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity; Must have been prescribed by a medical practitioner, Must conform to the professional standards widely accepted in international medical practice or by the medical community in India. 14. Network Provider Network Provider means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility. 15. Non- Network Any hospital, day care Centre or other provider that is not part of the network 16. Pre-Existing Disease Any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and / or were diagnosed, and / or received medical advice / treatment within 48 months to prior to the first policy issued by the insurer [Life Insurers can define norms for applicability at reinstatement]. 17. Qualified Nurse Qualified nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India. 18. Reasonable Charges Reasonable 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. 19. Surgery Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day care centre by a medical practitioner 20. OPD treatment OPD treatment is 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 a day care or in-patient.
4 21. Hospitalization Means admission in a Hospital for a minimum period of 24 consecutive hours Inpatient Care except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours. 22. Illness Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment. 23a Acute condition - Acute condition is a medical condition that can be cured by Treatment 23b. Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics: It needs ongoing or long-term monitoring through consultations, examinations, checkups, and / or tests It needs ongoing or long-term control or relief of symptoms It requires your rehabilitation or for you to be specially trained to cope with it It continues indefinitely It comes back or is likely to come back. 23. Day care center A day care center means any institution established for day care treatment of sickness and / or injuries or a medical set-up within 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 criteria as under:- has qualified nursing staff under its employment; has qualified medical practitioner (s) in charge; has a fully equipped operation theatre of its own where surgical procedures are carried out & maintains daily records of patients and will make these accessible to the Insurance company s authorized personnel. 24. Injury Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner. 25. Medical Advice Any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription 26. Medical expenses Medical Expenses means those expenses that an Insured Person has necessarily and actually 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
5 had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment. 27. Pre-hospitalization Medical Expenses Medical Expenses incurred immediately before the Insured Person is Hospitalized, provided that: Such Medical Expenses are incurred for the same condition for which the Insured Person s Hospitalization was required, and The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company. 28. Post-hospitalization Medical Expenses Medical Expenses incurred immediately after the Insured Person is Hospitalized, provided that: Such Medical Expenses are incurred for the same condition for which the Insured Person s Hospitalization was required, and The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company. 29. New Born Baby Newborn Baby means those babies born to you and your spouse during the Policy Period Aged between 1 day and 90 days. 30. Cumulative Bonus Cumulative Bonus shall mean any increase in the sum assured / Mallus granted by the insurer without an associated increase in premium. 31. Maternity expense Maternity expense / treatment shall include the following Medical treatment Expenses: Medical Expenses for a delivery (including complicated deliveries and caesarean sections) incurred during Hospitalization; The lawful medical termination of pregnancy during the Policy Period limited to 2 deliveries or terminations or either during the lifetime of the Insured Person; Pre-natal and post-natal Medical Expenses for delivery or termination. 32. Dental Treatment Dental treatment is treatment carried out by a dental practitioner including examinations, fillings (where appropriate), crowns, extractions and surgery excluding any form of cosmetic surgery/implants. 33. Any one illness Any one illness means continuous Period o f illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken.
6 34. Congenital Anomaly Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position. 34a. Internal Congenital Anomaly Which is not in the visible and accessible parts of the body is called Internal Congenital Anomaly 34b. External Congenital Anomaly Which is in the visible and accessible parts of the body is called External Congenital Anomaly. 35. Unproven/Experimental treatment Unproven/Experimental treatment is treatment, including drug Experimental therapy, which is based on established medical practice in India, is treatment experimental or unproven. 36. Condition Precedent Condition Precedent shall mean a policy term or condition upon which the Insurer's liability under the policy is conditional upon. 37. Notification of Claim Notification of claim is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address / telephone number to which it should be notified. 38. Disclosure to information norm The Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact. 39. Cashless facility Cashless facility means a facility extended by the insurer to the insured where the payments, of the costs of treatment undergone by the insured in accordance with the policy terms and conditions, are directly made to the network provider by the insurer to the extent preauthorization approved. 40. Subrogation Subrogation shall mean the right of the insurer to assume the rights of the insured person to recover expenses paid out under the policy that may be recovered from any other source. 41. Contribution Contribution is essentially the right of an insurer to call upon other insurers, liable to the same insured, to share the cost of an indemnity claim on a ratable proportion. 42. Renewal Renewal defines the terms on which the contract of insurance can be renewed on mutual consent with a provision of grace period for treating the renewal continuous for the purpose of all waiting periods.
7 43. Portability Portability means the right accorded to an individual health insurance policy holder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break. 44. Room rent (Being reviewed matter referred to IRDA) 45. Alternative treatments Alternative treatments are forms of treatments other than treatment Allopathy or modem medicine and include Ayurveda, Unani, Sidha and Homeopathy in the Indian context
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