What are Inclusions and Exclusions under a Super Top-up Policy?
When buying a super top-up policy, go through the policy document carefully to learn the extent of coverage of the plan. While the policy will pay for several expenses related to your healthcare needs, there still are certain limitations. Knowing these limitations or exclusions will help you in raising a claim without any confusion and facilitate its proper settlement.
Inclusions are the extent of cover that the super top-up health insurance would provide. You will find the inclusions, as per the insurer, on the policy document. These inclusions as well as the terms and conditions of the policy and the premium may differ from insurer to insurer. For every policy, there is a limit up to which it offers coverage. There are certain situations that the insurer may not cover and these are known as exclusions of the policy. The exclusions also vary between different insurers. Generally, insurers mention the exclusions on the policy documents so that you can have a hassle-free claim settlement. Read on to know about what the super top-up insurance covers and what it does not cover.
Once the expenses exceed the deductible amount of a health insurance plan,
a super top-up policy
covers claims for all your additional medical expenses within a policy year. The deductible is the amount that a policyholder has to pay out of his pocket. The policy includes the following:
Standard inclusions of a super top-up plan are:
It pays the total claims for medical expenses during the policy term once it exceeds the deductible. It offers robust cover during medical emergencies. A major surgery, critical illness or a disease that needs long-term treatment—all these can raise your healthcare expenses exponentially. Meanwhile, this plan can help you avoid digging into your savings as it offers a sum insured (SI) between Rs 5 lakh and Rs 1.30 crore.
This policy covers the fees of doctors, surgeons, medical practitioners, anaesthetists and nurses, diagnostic tests, anaesthesia, surgical appliances, blood, oxygen, medicines, and OT charges.
Cost of implants
The cost of artificial body parts and internal implantations such as pacemakers are covered as a part of the surgery.
Pre/Post Hospitalisation Costs
The policy covers expenses before and after hospitalisation
Expenses for daycare treatment are covered by the policy. Daycare treatment does not require a 24-hour hospital stay.
ICU Charges and Room Rent
Room rent, nursing expenses, and ICU expenses are covered under this policy.
Road Ambulance Charges
It is one of the most critical and basic facilities required during a medical emergency. A super top-up plan includes the cost of ambulance service.
Complimentary Annual Health Check-up
This policy provides a complimentary annual health check-up for all members who are insured. You can get this facility after the completion of a certain duration of the policy period.
Apart from covering for several diseases, this plan also provides:
- Hospitalisation and treatment cover in India and abroad
- Travel by road and air ambulance
- Maternity expenses during hospitalisation and home-care up to certain limits
- Premium waiver if you are diagnosed with a critical illness
- Free health check-up to find out health problems
- Exemption of deductibles in case of hospitalisation due to accidents
- Attractive discounts under various categories
- Option to customise your plan
- Individual and family floater policies
- Coverage for parents-in-law
- Coverage for COVID-19 with a waiting period of 15 days
- No Claim Bonus during renewals
Standard exclusions of a super top-up plan are:
No claim unless the expenses exceed deductibles
You can only claim your super top-up health insurance after you have exhausted the entire sum insured under your existing health insurance policy. Otherwise, you can claim if you have already spent the deductible amount from your pocket. You have to pay the deductible only once.
In case of a pre-existing disease, you have to undergo a waiting period. If you raise a claim within the waiting period, the insurer will not settle the claim.
Hospitalisation without recommendation
If you or any of your family members get hospitalised without a recommendation from the doctor, your claim will not get settled. Also, if you get hospitalised for any condition that does not match with the symptoms or disease mentioned in the doctor's prescription, your claim will get rejected.
Pre and Post-natal expenses
If you claim for expenses related to pre and post-natal medical costs, your insurer may not cover it. Some insurers cover these expenses if it requires hospitalisation.
Other exclusions consist of:
- Investigation and evaluation
- Rest cure, rehabilitation and respite care
- Obesity/ weight control unless life-threatening
- Change-of-gender treatments
- Cosmetic or plastic surgery unless for accident, cancer or burns
- Hazardous or adventure sports
- Breach of law
- Excluded Providers
- Drugs or treatments
- Wellness and rejuvenation
- Dietary supplements and substances
- Refractive error
- Birth control, sterility and infertility
- External congenital anomaly
- Outpatient treatment
- Treatment other than medically necessary treatment
- Charges other than reasonable and customary charges
- Overseas treatment except for benefits provided under the worldwide emergency Cover
- Self-injury or suicide
- Treatment outside discipline
- Nuclear attack
Go through the inclusions and exclusions of a super top-up policy before you buy it. You will find that the coverage would vary between different insurers. A clear understanding of the extent of coverage would help you while raising a claim.