Page 212 - DCOM309_INSURANCE_LAWS_AND_PRACTICES

Unit 12: Health and Catastrophe Insurance

In the next unit, you will study about the privatization of insurance sector. The unit will update Notes
you about the current scenario of insurance industry in India and the opportunities and challenges
in insurance sector today. The next unit will also summarise the way ahead for insurance sector.

12.1 Features of Health Insurance Policy

Now, let us study about the features of health insurance policy. Any health insurance policy
should cover the following the expenses:

1. The policy should provide for reimbursement of hospitalisation/domiciliary
hospitalisation expenses for illness/disease suffered or accidental injury sustained during
the policy period.
Hospital/Nursing Home: It means any institution in India established for indoor care and
treatment of sickness and injuries, which–
(a) Has been registered either as a hospital or nursing home with the local authorities
and is under the supervision of a registered and qualified medical practitioner.

(b) Should comply with the minimum criteria as under:
It should be equipped with at least 15 in-patient beds.
Fully equipped operation theatre of its own where the surgical operations are
carried out.
Availability of fully qualified nursing staff round the clock. Fully qualified
doctor(s) should be in charge round the clock.

The term Hospital/Nursing Home shall not include an establishment which is a place of
rest, a place for the aged, a place for drug addicts or place for alcoholics, a hotel or a similar
place.

Domiciliary Hospitalisation Benefit means medical treatment for a period exceeding
three days for such illness/injury which in the normal course would require treatment at
the hospital/nursing home but actually taken whilst confined at home in India under any
of the following circumstances namely:

(i) The condition of the patient is such that he/she cannot be removed to the hospital/
nursing home, or
(ii) The patient cannot be removed to hospital/nursing home due to lack of
accommodation therein.
2. The policy should pay during the period of insurance maximum up to the sum insured for
expenses incurred under the following heads:

(a) Room, Boarding Expenses in the Hospital/Nursing Home,
(b) Nursing Expenses,
(c) Surgeon, Anaesthetist, Medical Practitioner, Consultants. Specialist fees, and

(d) Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances,
Medicines and Drugs, Diagnostic Materials, and X-Ray, Dialysis, Chemotherapy,
Radiotherapy, Cost of Pacemaker, Artificial Limbs and Cost of organs and similar
expenses.
3. Reimbursement is allowed only when treatment is taken in a hospital or nursing home
which satisfies the criteria specified in the policy.

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