Page 307 - DMGT303_BANKING_AND_INSURANCE

Banking and Insurance

Notes
Figure 14.3: Payment Obligations

The Individual Policy-Holder's Payment Obligations

Premium

Exclusions

Deductible

Coverage limits

Copayment

Out-of-pocket
maximums

Coinsurance

Capitation

In-Network Provider

Generally, providers in-network are those who have a contract with the insurer to accept further
discounted rates from the "usual and Customary" fees /charges the insurer pays to out-of-
network providers.

Eligibility for Taking Policy

Persons between the age of 5 years and 75 years can get this insurance. Children between the age
of 3 months and 5 years of age can be covered provided one or both parents are covered
currently. Persons of any nationality can take this policy.

Conditions for Reimbursement

Expenses on hospitalization for a minimum period of 24 hours are allowable except in case of
specific treatments i.e. dialysis, chemotherapy, radiotherapy, eye surgery, dental surgery,
lithography (kidney stone removal), tonsillectomy, D and C taken in the hospital/nursing
home and the insured is discharged on the same day. In these cases, the treatment though less
than 24 hours will be considered under hospitalization benefits.

The Heads of Reimbursable Expenses

1. Boarding expenses for room provided by the hospital/nursing home.
2. Nursing expenses.

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