Knowledge Centre

How Does Health Insurance Work ?

Let’s say you found your perfect health insurance plan, you made a decision and you bought it. Now that’s a first. Typically, your medical insurance is offered on yearly basis and it has to be renewed each year after expiry. Now, during the term of your coverage, in the event of hospitalization of an insured person, it’s evident that you will make a claim for your healthcare needs. Now, the insurance company, in case of a claim, first checks whether the treatment that is required by the insured is covered under the insurance policy.

If it’s covered by the plan, the next step the insurer does is to find out if the hospital where the insured is getting his treatment is in its network. If you’re getting your treatment with a networked hospital, then congratulations, you’re eligible for a cashless hospitalization and the TPA (Third Party Administrators) are the ones responsible for settling your hospitalization bills. TPA’s will verify the details of your mediclaim policy and if it has a deductible clause or if the total amount of your bills exceed the amount of your sum insured, you just have to pay your share of the bill and the rest will be taken care by your insurer. And if no such clause applies, you walk out of the hospital as if nothing ever happened to you without paying even a single penny. Yes, that does feel good!

Now, let’s assume your hospital is not in the list of insurer’s network, then there’s a different procedure where you have to collect all your medical bills that also includes pre & post hospitalization bills and submit them to your insurer collectively. Again, the TPA will check the clauses of your policy and calculate the total amount to be reimbursed after deducting the co-pay amount (if any) or the amount that exceeds your insurance coverage. The balance or the entire amount of your bills - whichever is applicable, will be directly reimbursed by the insurance company and in any case, the insured walks out happily.

There might be cases, where the treatment will not be covered by your medical insurance policy. In such cases, the insurance company is helpless to assist you with your healthcare needs.

However, in any of the above cases discussed,

  • Expiry of your Insurance coverage term

  • Claims settled under cashless hospitalization facility

  • Claims settled and amount reimbursed to the insured

  • Treatment not covered by your insurance policy

If you’re unhappy with your insurance policy, you’re free to port your insurance to any other insurance provider. However, if that’s not the case and you’re happy with your current policy coverage then your insurance company is ready to greet you with open arms for a renewal and will always suggest you to consider upgrading your insurance coverage as it is always recommended to have a sufficient cover in any case of emergency.

Cheers to your happy and a healthy life!

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