Page 153 - IC38 GENERAL INSURANCE

a) DOMICILIARY HOSPITALIZATION

Although this benefit is not commonly used by policyholders, an individual
health policy also has a provision to take care of expenses incurred for
medical treatment taken at home without being admitted to a hospital.
However, the condition is that though the illness requires attention at a
hospital, the condition of the patient is such that he cannot be moved to a
hospital or there is lack of accommodation in hospitals.

This cover usually carries an excess clause of three to five days meaning
that treatment costs for the first three to five days have to be borne by the
insured. The cover also excludes domiciliary treatments for certain chronic
or common oilments such as Asthma, Bronchitis, Chronic Nephritis and
Nephritic Syndrome, Diarrhoea and all type of Dysenteries including
Gastroenteritis, Diabetes Mellitus Epilepsy, Hypertension, Influenza, Cough
and Cold, fevers.

b) COMMON EXCLUSIONS

Some of the usual exclusions under hospitalization indemnity policies are
given below. These are based on the suggested exclusions detailed in the
Guidelines on Standardization in Health Insurance issued by IRDAI
particularly Annexure IV. The student is advised to acquaint himself with the
guidelines available on the IRDAI website.

It must be noted that if any of the exclusions are waived or any additional
exclusions are imposed as per File and Use approved terms, these must be
stated separately in the Customer Information Sheet and the policy.

1. Pre-existing diseases

This is almost always excluded under individual health plans since otherwise
it would mean covering a certainty and poses a high risk to the insurer. One
of the important disclosures required at the time of taking a health policy is
regarding previous history of ailments / injuries of each insured person
covered. This will enable the insurer to decide on accepting the proposal for
insurance.

Definition

The IRDA guidelines on standardisation define Pre-existing as
“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 prior to the first policy issued by the
insurer.”

147