1. Premium

The premium is the fixed amount that the policyholder pays to the insurer to maintain the insurance coverage. It can be paid monthly, quarterly, annually, or as a one-time payment, depending on the policy terms.

2. Policyholder

The individual or entity that owns the insurance policy and is responsible for paying the premiums.

3. Coverage

Coverage refers to the range of medical expenses that the insurance policy will pay for, such as hospitalization, surgeries, Maternity.

4. Policy Term

The policy term is the duration for which the insurance policy remains active. It could range from one year to several years, depending on the policy type.

Claim-Related Terms

5. Claim

A claim is a formal request made by the policyholder to the insurance company to pay for covered medical expenses.

6. Reimbursement Claim

In a reimbursement claim, the policyholder pays the medical expenses upfront and later submits a claim to the insurer for reimbursement.

7. Medical Claims Ratio (MLR)

The MLR means the ratio of claims incurred to premiums earned per contract expressed as a ratio or percentage.

Coverage-Related Terms

8. Inpatient Treatment

Inpatient treatment refers to medical treatment where the patient is admitted to the hospital and stays for more than 24 hours.

9. Outpatient Treatment (OPD)

OPD refers to medical consultations and procedures that do not require hospital admission.

10. Daycare Procedures

Daycare procedures are treatments that don’t require 24-hour hospitalization due to advancements in medical technology. Common examples include cataract surgery, chemotherapy, and dialysis.

Exclusions and Limitations

11. Exclusions

Exclusions are specific medical conditions or treatments that are not covered under the insurance policy. These are clearly listed in the policy document.

12. Waiting Period

The waiting period is the time frame during which certain benefits are not available. For example, coverage for pre-existing conditions typically begins after a waiting period of 1 to 4 years.

13. Sub-Limit

A sub-limit is a cap imposed on specific expenses under the policy, such as room rent or maternity benefits.

14. Deductible

A deductible is the amount the policyholder must pay out of pocket before the insurer starts covering the expenses.

15. Co-Payment

Co-payment is a cost-sharing arrangement where the policyholder agrees to bear a percentage of the claim amount. For example, a 10% co-pay means the insurer will cover 90% of the claim, and the policyholder will pay the remaining 10%.

Other Important Terms

16. Network Hospital

A network hospital is one that has a direct tie-up with the insurance company, allowing for cashless treatment.

17. Non-Network Hospital

A non-network hospital does not have a tie-up with the insurer. Claims from these hospitals are reimbursed rather than settled directly. The member has to seek authorisation first to be able to access them.

18. Pre-Existing Condition

A pre-existing condition is any illness or medical condition that the insured had before purchasing the policy. Coverage for pre-existing conditions is usually subject to a waiting period.