This refers to the time during which the insurer is not liable to honour a claim. Most insurers impose a window of 30 days during which no claim is payable except in case of an emergency or an accident. This waiting period is also referred to as “Cooling period.” The duration of the cooling window may vary from insurer to insurer.
There are certain illnesses which are covered after a minimum waiting period. This waiting period can range from one to two years based on the policies of the insurer in question. This is referred to as “Exclusions.” Apart from Pre-existing Diseases (PED), certain types of injuries, health conditions, and other forms of medical expenditure are not covered in general by insurers. You will need to assess these aspects. For example, injuries resulting from war, expenses incurred for diagnosis, costs related to cosmetic treatment and cosmetic surgery, cosmetic dental treatment costs, expenses incurred for purchase of eye gear – spectacles, lenses, etc are generally not covered in health insurance policies. By checking this, you can avoid the heartburn of facing a claim rejection later.
Pre-existing Diseases (PED):
Pre-existing Diseases declared by customers also have waiting period. This is subject to the insurer approving the PED as an acceptable risk. The PED waiting period may range from two to three years – this is again based on policies of insurers and may vary.
Essentially, an insurance policy with a co-pay clause requires that the insured pays a percentage of the medical expenses out of their pocket before the insurer comes in and pays the rest of the amount. The percentage ranges between 10 – 25%. So for every Rs.100, the insured pays between Rs.10 – Rs.25 and the insurer pays the remaining amount.
Sub-limits are upper limits imposed on various aspects of hospitalization. Therefore, all costs lower than your sum assured may not be approved by your insurance company. Thus, resulting in unexpected outgo from your pocket. Sub-limits are imposed to limit claims outgo and is restricted to some common ailments such as piles, hernia, cataract, kidney stones, etc. Of course, the list of ailments and sub-limit factors vary from insurer to insurer. While sub-limits are not largely prevalent for individual health insurance plans, group insurance policies have such limits.