When you or your family get a health insurance policy, it can sometimes feel like reading a book in another language. There are so many terms and definitions that it can be confusing. But don't worry! We're going to break down the important definitions in Insurance, explaining them in a way that's easy to understand. Let's get started!
1. Accident
Definition: An accident is a sudden, unforeseen, and involuntary event caused by external, visible, and violent means.
Explanation: Imagine you're riding your bike, and you suddenly hit a rock and fall off. That unexpected fall is an accident. It's something that happens suddenly and wasn't planned, and it causes harm, like getting bruises or cuts. In the world of insurance, an accident is any event like this that results in physical injury.
2. Any One Illness
Definition: Any one illness means a continuous period of illness, including relapse within 45 days from the date of the last consultation with the hospital or nursing home where treatment was taken.
Explanation: Think about the last time you had the flu. You were sick for several days, then felt better. If you get sick again within 45 days with the same symptoms, insurance considers it as part of the same illness period. It’s like when you miss school for a few days, feel better, go back, and then get sick again quickly – it's still considered the same illness episode.
3. AYUSH Hospital
Definition: An AYUSH hospital is a healthcare facility where traditional Indian treatments such as Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy are provided.
Explanation: Imagine a hospital that doesn't just use modern medicine but also uses ancient Indian ways to treat people. These traditional methods are grouped under the term AYUSH. So, if someone prefers natural treatments, they can go to an AYUSH hospital.
4. AYUSH Day Care Centre
Definition: A place where traditional Indian treatments are provided on a day-care basis without requiring an overnight stay.
Explanation: This is like a clinic where you can go for treatments like Yoga or Ayurveda and return home the same day. It’s similar to visiting a dentist for a filling and coming back home afterward, but here it’s for traditional treatments.
5. Cashless Facility
Definition: A facility where the insurance company directly pays the hospital for the insured person's treatment.
Explanation: Imagine you have to go to the hospital, but you don't have to worry about paying the bill right away. The insurance company handles the payment directly with the hospital. It’s like having a magical card that covers your expenses without you needing to pay upfront.
6. Condition Precedent
Definition: A policy term or condition upon which the insurer’s liability under the policy is conditional.
Explanation: This means there are certain rules you must follow for the insurance company to pay for your treatment. If you don't follow these rules, they might not cover the costs. Think of it as a promise you make to do your homework, and only then will you get your allowance.
7. Congenital Anomaly
Definition: A condition present since birth that is abnormal with reference to form, structure, or position.
Explanation: Some babies are born with health conditions like a hole in the heart or a cleft lip. These are called congenital anomalies. It means the baby has a condition that existed from birth and is different from the normal body structure.
8. Co-Payment
Definition: A cost-sharing requirement under a health insurance policy that provides that the policyholder will bear a specified percentage of the admissible claims amount.
Explanation: Let’s say you have to pay for a school trip, and your parents agree to cover 80%, but you need to pay the remaining 20% from your pocket money. Co-payment in insurance works similarly, where the insurance pays most of the bill, but you also contribute a small part.
9. Cumulative Bonus
Definition: An increase or addition in the sum insured granted by the insurer without an associated increase in premium.
Explanation: If you don’t get sick or make a claim in a year, the insurance company rewards you by increasing your coverage amount for the next year without charging you extra. It’s like getting bonus points for good behavior that you can use later.
10. Day Care Centre
Definition: An institution established for day care treatment of illness and/or injuries, or a medical setup with a hospital.
Explanation: This is a place where you can get treatments or surgeries that don’t require you to stay overnight. Imagine getting a small surgery and going home the same day, just like you do with a dentist visit.
11. Day Care Treatment
Definition: Medical treatment and/or surgical procedures undertaken under general or local anesthesia in a hospital/daycare center in less than 24 hours.
Explanation: This means certain treatments or surgeries can be done quickly and don't require you to stay in the hospital overnight. For example, getting your tonsils removed might be a day care treatment because you can go home the same day.
12. Deductible
Definition: A specified amount that the insured person must pay out of pocket before the insurance company pays any expenses.
Explanation: Think of this as the initial amount you pay before your insurance helps cover the rest. For example, if your deductible is ₹1,000 and you have a hospital bill of ₹5,000, you pay the first ₹1,000, and the insurance pays the remaining ₹4,000.
13. Dental Treatment
Definition: Treatment related to teeth or structures supporting teeth, including examinations, fillings, crowns, extractions, and surgery.
Explanation: This covers all the visits to the dentist, whether it’s for cleaning, getting a cavity filled, or even braces. Anything related to keeping your teeth healthy falls under dental treatment.
14. Disclosure of Information Norm
Definition: 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.
Explanation: This rule means you must be completely honest when filling out your insurance forms. If you lie or hide important information, your insurance won’t pay for your treatment. It’s like getting disqualified from a game for not following the rules.
15. Domiciliary Hospitalization
Definition: Medical treatment for an illness which would normally require care and treatment at a hospital but is actually taken at home under any of the following circumstances: the patient is not in a condition to be moved to a hospital, or there is no availability of a room in the hospital.
Explanation: Sometimes, you might need to be treated at home instead of the hospital because there are no beds available or you’re too sick to travel. This is called domiciliary hospitalization, where home becomes the hospital.
16. Emergency Care
Definition: Management for an illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care.
Explanation: This is when you need urgent treatment for something serious that happens all of a sudden, like breaking your arm or having a severe allergic reaction. It’s when you need to rush to the hospital quickly.
17. Grace Period
Definition: 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.
Explanation: If you forget to pay your insurance on time, the grace period gives you a little extra time to make the payment without losing your benefits. It’s like getting an extra few days to submit your homework without penalty.
18. Hospital
Definition: An institution established for in-patient care and day care treatment of illness and/or injuries, which has been registered as a hospital with the local authorities.
Explanation: A hospital is a place where you go when you are very sick or injured and need serious medical treatment. It has doctors, nurses, and all the necessary equipment to take care of patients.
19. Hospitalization
Definition: Admission in a hospital for a minimum period of 24 consecutive hours except for specified procedures/treatments.
Explanation: This means staying in the hospital for at least one full day and night to receive treatment. Some special treatments can be done quicker, but usually, hospitalization means being admitted for at least 24 hours.
20. Illness
Definition: A sickness or a disease or pathological condition leading to the impairment of normal physiological function and requiring medical treatment.
Explanation: Illness is when you feel unwell or have a disease that makes it hard for your body to function normally, like having the flu, chickenpox, or diabetes. It’s any condition that makes you sick and needs a doctor’s help.
21. Injury
Definition: Physical harm excluding illness or disease solely and directly caused by external, violent, and visible means.
Explanation: Injury is when you get hurt, like getting a cut, bruise, or broken bone from falling or having an accident. It’s different from being sick because it’s caused by something outside your body, like falling off a bike.
22. Inpatient Care
Definition: Treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.
Explanation: Inpatient care means you need to stay in the hospital overnight or longer for treatment. It’s like having a sleepover at the hospital but for medical reasons, not for fun.
23. Intensive Care Unit (ICU)
Definition: 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.
Explanation: The ICU is a special part of the hospital for patients who are very sick and need constant attention and special medical equipment to monitor and treat them. It’s like the VIP section for very sick patients.
24. ICU Charges
Definition: The amount charged by a hospital towards ICU expenses, including the expenses for ICU bed, general medical support services provided to any ICU patient, including monitoring devices, critical care nursing, and intensivist charges.
Explanation: These are the costs for staying in the ICU, which includes the bed, medical equipment, and special care you receive. It’s more expensive than regular hospital rooms because of the extra care and technology used.
25. Medical Advice
Definition: Any consultation or advice from a medical practitioner including the issuance of any prescription or follow-up prescription.
Explanation: Medical advice is when a doctor tells you what’s wrong and what you should do to get better. This includes giving you a prescription for medicine or telling you to rest.
26. Medical Expenses
Definition: 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.
Explanation: Medical expenses are all the costs you have to pay for treatment when you’re sick or injured, like doctor’s fees, hospital bills, and the cost of medicines.
27. Medical Practitioner
Definition: A person who holds a valid registration from the Medical Council of any state or Medical Council of India or Council for Indian Medicine or for Homeopathy set up by the Government of India or a state government and is thereby entitled to practice medicine within its jurisdiction.
Explanation: A medical practitioner is a doctor who is officially allowed to treat patients. They have to be registered and licensed to practice medicine.
Understanding the terms of your health insurance policy is crucial for making informed decisions and maximizing your benefits. We hope this guide has helped clarify the key definitions in the Health Insurance Policies in India. For more detailed information on coverage options and to explore how Health Insurance can protect you and your family, visit . If you have any questions or need personalized advice, book a free expert consultation with us today. Your health and peace of mind are our top priorities.
