Health Insurance Terms Glossary

Standard Definitions of terminology used in Health Insurance Policies

“Accident” means an unexpected, unforeseen and undesirable event, especially one resulting in bodily injury. “Bodily Injury” means any accidental physical bodily harm solely and directly caused by external, violent and visible and evident causes but does not include any sickness or disease.
A co-payment is a cost-sharing requirement under a health insurance policy that provides that the insured will bear a specified percentage of the admissible claim amount. A co-payment does not reduce the sum insured.

Day care treatment refers to medical treatment, and/or surgical procedure which is:

  • undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement, and
  • which would have otherwise required a hospitalization of more than 24 hours.

Treatment normally taken on an out-patient basis is not included in the scope of this definition.

A deductible is a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee amount in case of indemnity policies and for a specified number of days/hours in case of hospital cash policies which will apply before any benefits are payable by the insurer. A deductible does not reduce the sum insured.
Domiciliary hospitalization means medical treatment for a period exceeding 3 days, for an illness/disease/injury which in the normal course would require care and treatment at a hospital but is actually taken while confined at home under any of the following circumstances:
  • The condition of the patient is such that he/she is not in a condition to be removed to a hospital, or
  • The patient takes treatment at home on account of non-availability of room in a hospital.
Emergency care means management for a severe illness or injury which results in symptoms which occur suddenly and unexpectedly, and requires immediate care by a medical practitioner to prevent death or serious long term impairment of the Insured person’s health.
Grace period means the specified period of time immediately following the premium due date during which a payment can be made to renew or continue a policy in force without loss of continuity benefits such as waiting periods and coverage of pre- existing diseases. Coverage is not available for the period for which no premium is received.

“Hospital” means any institution established for in-patient care and day care treatment of illness and/or injuries and which has been registered as hospital with the local authorities under the Clinical Establishments (Registration and Regulation) Act, 2010 or under the enactments specified under the Schedule of section 56 (1) for the said act OR complies with all the minimum criteria as under:

  • has qualified nursing staff under its employment round the clock
  • has at least 10 inpatient beds, in those towns having a population of less than 10,00,000 and at least 15 in-patient beds in all other places;
  • has qualified Medical Practitioner(s) in-charge round the clock
  • has fully equipped operation theatre of its own, where surgical procedures are carried out
  • maintains daily records of patients and makes these accessible to the Insurance company’s authorized personnel
Intensive care unit means an identified section, ward or wing of a hospital which is under the constant supervision of a dedicated medical practitioner(s), and which is specially equipped for the continuous monitoring and treatment of patients who are in a critical condition, or require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the ordinary and other wards.
Inpatient care means treatment for which the Insured person has to stay in a hospital for more than 24 hours for a covered event.

Medically necessary treatment is defined as any treatment, tests, medication, or stay in hospital or part of a stay in hospital which

  • is required for the medical management of the illness or injury suffered by the insured;
  • must not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration, or intensity;
  • must have been prescribed by a medical practitioner;
  • must conform to the professional standards widely accepted in international medical practice or by the medical community in India.
"Network Provider” means hospitals or health care providers enlisted by an insurer or by a TPA and insurer together to provide medical services to an insured on payment by a cashless facility.
Any hospital, day care centre or other provider that is not part of the network.
Any condition, ailment or injury or related condition(s) for which the insured 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 insurer.
Qualified nurse is a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India and who is employed on recommendations of the attending Medical Practitioner.
Reasonable charges means the charges for services or supplies, which are the standard charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the nature of the illness / injury involved.
Surgery or Surgical Procedure means manual and / or operative procedure (s) required for treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed in a hospital or day care centre by a medical practitioner.
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.
Means admission in a Hospital for a minimum period of 24 In patient Care consecutive hours except for specified procedures/ treatments, where such admission could be for a period of less than 24 consecutive hours.
Please refer to day-care surgeries list.

Illness means a sickness or a disease or pathological condition leading to the impairment of normal physiological function which manifests itself during the Policy Period and requires medical treatment.

  • Acute condition - Acute condition is a disease, illness or injury that is likely to respond quickly to treatment which aims to return the person to his or her state of health immediately before suffering the disease/ illness/ injury which leads to full recovery.
  • Chronic condition - A chronic condition is defined as a disease, illness, or injury that has one or more of the following characteristics:—it needs ongoing or long-term monitoring through consultations, examinations, check-ups, and/or tests—it needs ongoing or long-term control or relief of symptoms— it requires rehabilitation or to be specially trained to cope with it—it continues indefinitely—it comes back or is likely to come back.

A day care centre means any institution established for day care treatment of illness and / or injuries or a medical setup within a hospital and which has been registered with the local authorities, wherever applicable, and is under the supervision of a registered and qualified medical practitioner AND must comply with all minimum criteria as under –

  • has qualified nursing staff under its employment;
  • has qualified medical practitioner(s) in charge;
  • has a fully equipped operation theatre of its own where surgical procedures are carried out
  • maintains daily records of patients and will make these accessible to the Insurance company’s authorized personnel.
Injury means accidental physical bodily harm excluding illness or disease solely and directly caused by external, violent and visible and evident means which is verified and certified by a Medical Practitioner.
Any consultation or advice from a Medical Practitioner including the issue of any prescription or repeat prescription.
Medical Expenses means those expenses that an Insured person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

"Pre-hospitalization Medical Expenses" means Medical Expenses incurred immediately before the Insured person is hospitalized, provided that :

  • Such Medical Expenses are incurred for the same condition for which the Insured person’s hospitalization was required, and
  • The In-patient Hospitalization claim for such Hospitalization is admissible by the Insurance Company.

Medical Expenses incurred immediately after the insured person is discharged from the hospital provided that:

  • Such Medical Expenses are incurred for the same condition for which the Insured person’s hospitalization was required, and
  • The In-patient hospitalization claim for such hospitalization is admissible by the insurance company.
Newborn baby means those baby born during the Policy Period and is aged between 1 day and 90 days, both days inclusive.
Cumulative Bonus shall mean any increase in the sum Insured granted by the insurer without an associated increase in premium.

Maternity expenses shall include –

  • Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization)
  • Expenses towards lawful medical termination of pregnancy during the policy period
  • Pre-natal and post-natal Medical Expenses for delivery or termination covered only if specified in the policy.
Dental treatment is treatment carried out by a dental practitioner including examinations, fillings (where appropriate), crowns, extractions and surgery excluding any form of cosmetic surgery/implants.
Any one illness means continuous Period of illness and it includes relapse within 45 days from the date of last consultation with the Hospital/Nursing Home where treatment may have been taken.

Congenital Anomaly refers to a condition(s) which is present since birth, and which is abnormal with reference to form, structure or position.

  • Internal Congenital Anomaly which is not in the visible and accessible parts of the body is called Internal Congenital Anomaly
  • External Congenital Anomaly which is in the visible and accessible parts of the body is called External Congenital Anomaly.
Treatment including drug experimental therapy, which is not based on established medical practice in India, is treatment experimental or unproven.
Condition Precedent shall mean a policy term or condition upon which the Insurer's liability under the policy is conditional upon.
Notification of claim is the process of notifying a claim to the insurer or TPA by specifying the timelines as well as the address / telephone number to which it should be notified.
The Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, MIS-description or non-disclosure of any material fact.