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Coverages and Add-On Coverages in Health Insurance

In health insurance, coverages refer to the medical services and expenses that are included in your policy. Add-on coverages (also known as riders or supplemental coverages) are optional benefits you can include for additional protection, often at an extra premium.

Basic Coverages in Health Insurance:

1. Inpatient hospitalization – Costs of being admitted to the hospital.
2. Pre- and post-hospitalization – Medical expenses before and after hospitalization (usually up to 30 and 60 days, respectively).
3. Daycare procedures – Treatments that don't require 24-hour hospitalization (e.g., cataract surgery).
4. Ambulance charges – Transportation to the hospital in emergencies.
5. Doctor’s consultation and diagnostic tests – Covered under outpatient or sometimes inpatient.
6. Maternity and newborn cover – Offered in some plans, often with a waiting period.
7. Organ donor expenses – Costs related to organ transplant (excluding donor’s hospitalization).
8. Cashless facility – Available at network hospitals for direct settlement with insurer.

Common Add-On Coverages:

1. Critical illness cover – Lump sum payment if diagnosed with specified critical illnesses like cancer or heart attack.
2. Personal accident cover – Coverage for death or disability due to accidents.
3. Maternity and fertility treatments – More comprehensive maternity benefits or infertility treatments.
4. Hospital cash benefit – Daily allowance during hospitalization to cover non-medical expenses.
5. OPD cover – For outpatient consultations, medicines, and diagnostics.
6. Top-up plans – High-deductible plans that activate once a threshold is crossed; used to enhance existing coverage.
7. International treatment coverage – For treatment abroad, typically for serious conditions.
8. Alternative treatments (AYUSH) – Coverage for Ayurveda, Yoga, Unani, Siddha, and Homeopathy treatments.
9. Dental and Vision Cover: Helps pay for dental procedures and eye care, which are often excluded from standard policies.
10. Room Rent Waiver: Removes the cap on hospital room rent, allowing access to better facilities.

Group Medical Insurance

Coverages Included:

1. Hospitalization Coverage

Inpatient hospitalization (room rent, ICU charges)
Surgery and operation theater charges
Doctor's fees and nursing charges

2. Pre- and Post-Hospitalization

Medical expenses incurred before and after hospitalization, usually up to a set number of days (e.g., 30 days prior, 60 days after)

3. Daycare Procedures

Covers procedures not requiring 24-hour hospitalization (e.g., cataract surgery, chemotherapy)

4. Maternity Benefits

Expenses related to childbirth, including normal and C-section deliveries
May include newborn baby cover for a limited time

5. Outpatient Department (OPD)

Some policies include or offer add-ons for doctor consultations, diagnostics, and pharmacy costs without hospitalization

6. Pre-Existing Diseases (PED)

Often covered from day one or after a short waiting period in group policies

7. Critical Illness

Covers major illnesses like cancer, stroke, or heart attack (may be an add-on)

8. Mental Health Coverage

Increasingly being included for psychiatric consultations and therapy

9. Ambulance Charges

For emergency transport to the hospital

10. Domiciliary Hospitalization

Treatment at home when hospital admission isn’t possible

Key Features:

1. Coverage

Covers a group of people (usually employees and sometimes their dependents)
Generally includes hospitalization, surgeries, doctor consultations, and sometimes maternity and pre/post-hospitalization expenses

2. Premium

Often paid by the employer, fully or partially
Lower premiums compared to individual health insurance due to group risk pooling

3. Benefits

No medical tests usually required for enrollment
Pre-existing conditions are often covered from day one
Cashless treatment available at network hospitals

4. Add-ons

Optional coverage for family (spouse, children, parents) at extra cost
Can include maternity benefits, wellness programs, and OPD coverage

5. Limitations

Coverage ends when employment ends
Sum insured may be lower than what’s needed for serious illnesses

Health & Accident Insurance