Page 155 - Ebook health insurance IC27

Sashi Publications

are subject to Bonus ( in case of favorable group claim experience) and
Malus ( in case of unfavorable group claim experience ).

Q16. Discuss the common clauses that are applicable in health insurance
products in India.

Ans. There are several common clauses provided with the health insurance products of
India. Many, of them though are modified by insurance companies, still form the
basis of guidelines.

(i) Limits of usage of 24 hours of hospitalization - Generally the minimum period
of hospitalization required is 24 hours. However, certain treatment/surgeries
requiring only a day are considered to be exceptions. They usually include Heamo
Dialysis Chemotherapy, Eye Surgery, D&C, Angioplasty, Hernia, Hydrocele, ENT
surgery, Cataract, etc.

(ii) Limits of usage - The hospitals where the treatment is taken have to be licensed
and registered, should be under the supervision of a registered medical practitioner,
should have minimum 15 beds for metros and large cities (10 in smaller towns),
etc. Such conditions ensure standard and established place and room for fraud is
tried to rule out.

(iii) Room rent - Often, in order to balance medical necessity and luxury, and cost
control to insures,somelimits to roomcharges areimposed, (say 1%ofsum insured).

(iv) Limits of indemnity - It is the maximum liability for any/all claims made during the
policy period, availed by the insured for hospitalization and other related claimable
events. This is stated in the policy schedule, and is also called sum insured.

Website : www.bimabazaar.com, PH: 033 22184184/40078428 159