A Medical practitioner is a person who holds a valid registration from the Medical Council of any state 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; and is acting within the scope and jurisdiction of his license.

Medically necessary treatment is defined as any treatment, tests, medication or stay in hospital or part of a stay in hospital which (a) is required for the medical management of the illness or injury suffered by the insured (b) must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity (c) must have been prescribed by a medical practitioner. (d) Must conform to the professional standards widely accepted in international medical practice or by the medical community in India.

“Network Provider” means network provider as defined in IRDAI (Third Party Administrators-Health Services) Regulations, 2016a. Insurance companies offer policies providing cashless services to the policyholders provided: The services are offered through network providers who have been enlisted to provide medical services under a direct written agreement with the insurer where there is a direct arrangement or by a tripartite agreement amongst health services provider, the TPA and the insurer where it is through a TPA. The Agreements shall cover the tariff applicable with respect to various kinds of healthcare services being provided by the network provider. A clause specifically fixing the onus on the Insurer to deny or repudiate a claim. The insurance company usually endeavour to enter into Agreements with adequate number of both public and private sector network providers across the geographical spread.

Means those babies born to the Insured person during the Policy Period aged between 1 day and 90 days.

As per Health Insurance regulations 2016 General Insurers and Health Insurers may endeavour to provide coverage for one or more systems covered under ‘AYUSH treatment’ provided the treatment has been undergone in a government hospital or in any institute recognized by government and/or accredited by Quality Council of India or National Accreditation Board on Health. Definition 2.d “AYUSH Treatment” refers to the medical and/or hospitalization treatments given under ‘Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems.”

Any hospital, day care centre or other provider that is not part of the network. For the purpose of claim settlement, insurer shall make direct payments to the policyholders by integrating their banking system platform. Provided that, if a claimant opts for payment through a cheque or Demand Draft, the insurer shall not deny such request.

Notification of claim is the process of notifying a claim to the Insurer or TPA by specifying the timeline as well as the address/telephone number to which it should be notified.

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.

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. As per HIR 2016 Policy is portable from one Insurer to another, 45 days prior to maturity of policy (including cumulative bonus would also be portable), as per Schedule I, Sec(1) & (18) of HIR 2016. One can transfer the policy from one Insurance company to another and the credits (including cumulative bonus) would also be portable.

Medical Expenses incurred for a period up to 60 days from the date of discharge from the hospital, provided that: Such Medical Expenses are incurred for the same condition for which the Insured Person’s Hospitalization was required, andThe In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.Common Clauses Health Insurance : Pre-existing diseases : Any condition, ailment or injury or related condition for which the insured person 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 insured. Generally *exclusions and pre-existing diseases* are not covered by a medical insurance policy (as specified in their policy document). Generally these *could be covered after 2-3-4 years of holding the policy*. Consumer must be honest in disclosing pre-existing ailments, if any.