Mediclaim was introduced in 1986, by GIC & covers individual as well as family from age of 5-80 years

IRDA introduced in 1999 & allowed private company to set up operations in India

Market Size & Forecasts

Market Size & Forecasts

•Only 2% of Indian population is covered under health insurance.•Health insurance is the fastest growing sector in non life insurance sector.

Family Floater health insurance & Mediclaim Health insurance & Mediclaim for Individuals Health insurance & Mediclaim for Senior

Citizens Overseas travel Insurance

Insurance Firms in India 23 firms in India (non life insurer)

23 firms (Major Ones are): AVIVA life Insurance Bajaj Allianz Bharti AXA ICICI Prudential LIC Max New York MetLife India

Fixed Benefit Policy: insured can make a claim even if he has already done so under policy from a non-life insurer. Therefore, the lump sum can be used to replace income lost during the period of treatment and recovery.

Reimbursement Policy: offer to reimburse the actual expenses incurred by the policyholder in the event of hospitalization.

Critical illness plan: amount is paid upon the diagnosis of the disease and not after hospitalization, providing a cushion if the need arises for meeting resultant expenses as well as lifestyle modifications costs. The end-use of the lump sum is not tied to illness, giving insured the freedom to spend it the way he choose.

Pre-Existing Illnesses 

If insured has undergone treatment for an ailment within 48 months before the policy was issued, the illness will not be covered 

Waiting Period Pre-existing illnesses will be covered only after a waiting period of 1-4 years 

No-Claim Period Claims other than those related to accidents cannot be made during the first 30 days of the health policy 

Sub-Limits Caps are placed by insurers on hospital room rent, surgeons charges, admissible claims on specific diseases, even if the total claim does not exhaust the limit

Co-Payment Its the share of eligible claim (10-25 %) that a policyholder agrees to pay. The higher insured contribution, the lower will be the premium 

Renewal 

Policy renewal requests cannot be turned down because of an earlier claim.  

Reasonability If hospital has charged,say,1 lakh for a treatment, which costs 50,000 elsewhere, claim payout will be restricted to the lower amount 

Exclusions Certain events or conditions wont be covered in the first year. For instance, suicide by the insured in the first year of a life insurance policy or piles/cataract in the first year of the health cover 

Indisputability Policyholders statements cannot be called into question after two years of issuing the policy 

Life Insurer General Insurer

Mostly new entrant Old players with long work ex

Premiums are fixed for 3-5 years depending on Policy & company

Premiums can go up after every year

Reimbursement cover is like general insurance, fixed benefits

ones hands out a pre defined sum

Reimburse only actual expenses occurred

If the fixed benefit exceeds the expenditure the balance is

returned to the insured

No such option

Premiums are higher Generally lower (1.7% for Bajaj Allainz, Indi. Health Guard)

Illness Accident Surgical requirement Symptoms, when diagnosis is been

done according to the document of Cholamandlam MS general Insurance

Pre hospitalization expenses (lab, X ray or all other diagnostic 60 days prior)

Hospitalization expenses (Diagnosis, Drugs, Procedures, cost of artificial limb & other equipments)

Post hospitalization expenses (max 90 days after discharge)

Also available on Extra premium: General health & eye examination Local ambulance services Hospital daily allowance

Treatment of illness at home i.e. without hospitalization (oriental Insurance now pays)

Pre existing diseases & circumcision Some diseases in first year (cataract, anal fistula etc.) Injuries or diseases attributable to war, invasion, act

of foreign enemy, war like operations, nuclear weapons/material

Cost of Specs., contact lens, Hearing Aids Dental treatment or Surgery Convalescence, general debility Tonics & vitamins (unless prescribed) Pregnancy, caesarean section, MTP Charges of diagnosis not leading to confirmation of

disease

1st 30 days any hospitalization is not covered except Accident cases

Not applied in case of renewal If breaks occurs in renewal then it applies

Insured has to bear 10% of the admissible claims

If insured opt for 20% payment than 10% of relaxation in premium allowed

Insured has to bear 10% extra of all the admissible claims for the claims arising out of pre-existing disease for which extra premium is paid

Pre Hospitalization Hospitalization Post Hospitalization

Days Covered

Apollo Munich(Medi Classic

Individual)

30 All except room which is 2% of SI max. upto 4000

7% of SI max. upto 5000

Royal Sundaram 30 60

Star Health (Easy Health Individual)

30- 60 (in case inform 5 days before Hospitalization)

All Except room which is 500Rs. Max. upto 3000 in network hospitals

60-90 (with same condition as pre)

Premium

Apollo Munich (5 month to 35 years)

1.5% (50k)-0.98% (500K) in multiple of 50K

Royal Sundaram (26-40 Years) 1 year premium

1.8% (100K)-1.37%(500K) in multiple of 50K

Star Health 1.20% (100K)- 1.21% (500K) in multiple of 100K

Max Age Covered

Apollo Munich (5 month to 35 years)

Not Available

Royal Sundaram 50 years (whole family is also covered)

Star Health Not Available

Exclusion of Pre existing Diseases

Apollo Munich (5 month to 35 years)

Not Available

Royal Sundaram After 4 years

Star Health Not Covered

Special Features (Medi Classic Individual) No Claim Discount ranging from 5% to 25% for every claim free year of

insurance (other than Family Package) Discount for voluntary deductibles ranging from 2% to 12% (other than

Family Package) 24 X 7 toll-free call centre. Cashless hospitalization in over 3200 network hospitals.Star Health (Easy Health Individual) Cover ambulance services if ambulance service is used on the way to

hospital for hospitalization (up to Rs. 2000). A comprehensive health check-up involving a number of medical tests at

the end of a block of 4 continuous claim-free years. Covers expenses involved in getting a treatment done at home which

otherwise would need hospitalization. Royal Sundaram (Health Shield Online) Ambulance referral facilities  Reimbursement of Health check up cost up to Rs.750 per insured person

after 5 claim free years of insurance Lump sum payment of 2% of Sum Insured  if hospitalization exceeds 15

consecutive days and where liability is admitted for hospitalization Room, Boarding Expenses as charged by the Hospital/Nursing Home

subject to a limit of 1.5% and for Intensive Care Unit 3% of the Sum Insured per day.

Pre Hospitalization

Hospitalization Post Hospitalization

Premium

Bajaj Allianz 1.7% (100K) to 1.09% (1000K)

ICICI Pru 1.98%(100K)

TATA AIG 1.11%

Max. age covered

Bajaj Allianz Up to 55 then up to 85

ICICI Pru 65

TATA AIG

Pre existing Diseases

Bajaj Allianz After 4 years

ICICI Pru Covered (notified ones)

TATA AIG