Page 156 - IC38 GENERAL INSURANCE

i. Sub limits and Disease specific capping

Some of the products have disease specific capping e.g. cataract. A few also
have sub limits on room rent linked to sum insured e.g. per day room rent
restricted to 1% of sum insured and ICU charges to 2% of sum insured. As
expenses under other heads such as ICU charges, OT charges and even
surgeon‟s fees are linked to the type of room opted for, room rent capping
helps in restricting expenses under other heads also and hence the overall
hospitalization expenses.

ii. Co-payment (popularly called Co-pay)

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 claim amount. A co-payment does not reduce the Sum
Insured.

This ensures that the insured exercises caution in selecting his options and
thus reduces his overall hospitalization expenses voluntarily.

iii. Deductible

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
in case of indemnity policies and for a specified number of days/hours in
case of hospital cash policies which will apply before any benefits are
payable by the insurer. A deductible does not reduce the Sum Insured.

Insurers are to define whether the deductible is applicable per year, per life
or per event and the specific deductible to be applied.

iv. New exclusions have been introduced and later standardized by IRDAI:

 Genetic disorders and stem cell implantation / surgery.

 External and or durable Medical / Non-medical equipment of any
kind used for diagnosis and or treatment including CPAP, CAPD,
Infusion pump etc., ambulatory devices i.e. walker, crutches, belts,
collars, caps, splints, slings, braces, stockings etc. of any kind,
diabetic foot wear, glucometer / thermometer and similar related
items etc. and also any medical equipment which is subsequently
used at home etc.

 Any kind of Service charges, Surcharges, Admission fees /
Registration charges etc. levied by the hospital

 Doctor‟s home visit charges, Attendant / Nursing charges during pre
and post hospitalization period

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