How soon can I claim from my (Medical) H&S Insurance?

This post is in response to my client’s call to me if a claim can be made for cataract surgery. Generally the following should be known about H & S claims

Waiting Period:-

  • Accidents – no waiting period. As long as application as been made and premium paid to company, coverage is immediate. This generally applies to all policies, PA and Life policies included
  • Illness eg fever, pneumonia – generally there will be a waiting period of 30 days, before any claims will be entertained
  • Specific illnesses – Normally insurers will have a list of illnesses that will not be covered for a specific number of days. MAA and most insurers now apply 120 days for this period ( previously this used to be one year)

MAA defines the following as SPECIFIC ILLNESS

  • Hypertension, Diabetes Mellitus and Cardiovascular Diseases
  • All Tumours, Cancers, Cysts, Nodules, Polyps, Stones of the Urinary System and Biliary System
  • All Ear, Nose (including sinuses) and Throat conditions
  • Hernias, Hemorrhoids (piles), Fistulae, Hydrocele, Varicocele
  • Endometriosis including disease of the Reproductive System
  • Vertebro-spinal Disorders (including disc) and Knee conditions

Note that the following conditions can also apply to coverage:-

Takeover policy– Where the policyholder discontinues a previous medical policy including that from a different insurer, and purchases this new insurance and is still in good health, generally a zero waiting period can be obtained for this new policy

Conditional Acceptance / Exclusion – There may be medical problems that may not be covered permanently, because it existed before the medical plan was taken up eg asthma, diabetes, etc. Any medical problems arising within the 30 days waiting period upon purchase or reinstatement after policy lapse will also not be covered

No coverage is provided for some type of treatment . They include Maternity, Cosmetic, Self-inflicted injuries, War, Psychotic, etc. Refer to your policy for more details

Coverage – H&S cards almost always provide cover for 3 instances :- Hospital Stay Treatment, Surgery & Out-patient Accidental  Treatment

Outpatient Treatment – Depending on the insurance policy, outpatient treatment is generally not covered. MAA MEDICALIFE however provides outpatient treatment for accidents, pre-hospital and post-hospital, kidney dialysis, cancer treatment, physiotherapy, etc

CASHLESS FACILITY – Generally if admission is in a PANEL HOSPITAL,  hospital will liaise with the Insurer and the patient will have to pay nothing or pay minimal non-claimable charges. If other than panel hospitals or out-patient, then the patient can “pay first and claim later” However, these are subject to approval based on factors such that the treatment involves surgery, in-stay at a recognised hospital, accidents and billing should not be higher than customary charges and also not involve non-claimable treatment

If you have a CASHLESS card, it is highly recommended that you use this benefit at a PANEL HOSPITAL and save the hassle of any dispute when claiming later. Simple example. Medical bill for cyst removed by a surgeon is claimable, cyst removed by a plastic surgeon may be disputable as it may be deemed cosmetic

Click here for more information on MAA MEDICALIFE H&S Card

Rama Krishnan



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