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Health care Terms & conditions

Terms & Conditions (T&Cs) area legal agreement between a service/website provider and its users, outlining rules, rights, and responsibilities for using a product or platform, also known as Terms of Service or Terms of Use , protecting both parties by defining acceptable behavior, managing expectations, limiting liability, and clarifying intellectual property. They're essential for setting expectations, preventing misuse, and legally safeguarding businesses, even if not always mandated by law. 

Key Terms Explained

  • Policy/Mediclaim: The document detailing the specific terms, inclusions, and conditions of your chosen health plan.

  • Sum Insured: The maximum amount the insurer pays for covered expenses in a year.

  • Waiting Period: A specific time after policy purchase during which certain treatments aren't covered (e.g., maternity, specific illnesses).

  • Co-payment: A fixed percentage or amount you pay for a claim, with the insurer covering the rest.

  • Pre-existing Conditions: Illnesses present before buying the policy, often covered after a waiting period (e.g., 2-4 years).

  • Moratorium Period (India): A 5-year period where insurers can't deny claims for non-disclosure unless fraud is proven, according to IRDAI regulations.

  • Medically Necessary Treatment: Care required for an injury/illness, conforming to accepted standards, and not exceeding necessary care. 

Health Terms & Conditions (T&Cs) are the legal rules in health insurance defining coverage, costs, and obligations, covering

What's Usually Covered (Inclusions)

  • Hospitalization Expenses: Room rent, doctor fees, diagnostics, medicines for stays >24 hours.

  • Pre-& Post-Hospitalization: Costs before admission and follow-ups after discharge.

  • Daycare Procedures: Treatments not requiring 24-hour admission.

  • Critical Illness: Lump-sum payout for specific severe diseases.

  • Maternity & Newborn Care: Expenses for pregnancy, delivery, and newborn care.

  • AYUSH: Alternative treatments (Ayurveda, Yoga, etc.). 

Important Things to Check

  • Exclusions: What the policy doesn't cover (e.g., cosmetic surgery, self-inflicted injuries).

  • Limits: Room rent caps, sub-limits for specific treatments, and overall sum insured.

  • Policy Tenure & Renewal: How long the policy lasts and renewal conditions.

  • Claim Process: How to file a claim (cashless vs. reimbursement). 

Understanding these terms prevents claim rejections and ensures your policy meets your needs, notes Star Health and PolicyX

Health Terms & Conditions (T&Cs) are the legal rules in health insurance defining coverage, costs, and obligations, covering
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