National Health Insurance

Financial Year	Claim Settlement Ratio
FY 2018-2019	85.47%
FY 2019-2020	83.78%

(Source: IBAI’s General Insurance Claim Insights Handbook For Policyholders - 4th & 5th Edition)

Network Hospitals of National Insurance Company

The network hospitals are the health facilities which are affiliated with the insurance provider and offer cashless treatment to its policyholders. Under the cashless treatment process, the insurer pays off the medical expenses directly to the hospitals on behalf of the insured individual. The more the number of network hospitals will be, the easier will be to find a hospital nearby for policyholders. The National Insurance Company has 6,000+ hospitals in its network, where you can get cashless treatment.

National Insurance Company Policy Terms

Here are the descriptions of the health insurance policy terms for the features and benefits offered by the National Insurance Company. However, the conditions of these insurance offerings may vary from plan to plan:

National Health Insurance Claim Process

The health insurance claim process is a system under which the insurance provider offers compensation for the medical expenses incurred due to any treatment through any injury and/or illness through hospitalisation. The claim process can be completed in two different ways which include cashless claim and reimbursement claim.

What is the Cashless Claim Process of National Health Insurance?

As per the cashless insurance claim process, the National Insurance Company makes the payment for your medical expenses when you get admitted in its network hospital. Under this system, you are not required to pay anything at the hospital other than any co-payment amount. All the cost is settled by the insurance provider directly with the hospital bill as per the terms and conditions of the health insurance plan.

Follow the below steps to easily raise a cashless claim with National Insurance Company:

Step 1: Intimate the Insurance Provider
Inform the National Insurance Company about your hospitalisation at least 72 hours in advance, in case of planned hospitalisation, and within 24 hours of admission, in case of emergency hospitalisation at 1800-345-0330.

Step 2: Pre-Authorisation Request
Get the cashless claim request form from the network hospital or the insurance provider to complete and submit it with other required medical documents at the insurance department or TPA desk of the hospital. The hospital will share those documents with the insurer for authorisation.

Step 3: Verification of Documents
The claim settlement team or TPA of National Insurance Company will verify the medical information, pre-authorisation form and required documents provided to them.

Step 4: Claim Approval
If the TPA or claim settlement team of the insurer requires any other information, they may ask for some other documents too. They reserve the right to deny pre-authorization requests if the policyholder is unable to provide the required medical details. On the rejection of the claim, the policyholder and hospital will be informed about the same.

Step 5: Settlement of Claim
At the time of discharge, the policyholder is required to verify and sign the discharge papers and make payment for non-medical and inadmissible expenses. After this, the network hospital sends the final request with the complete hospital bill. On receiving the same, the insurer will pay off your medical bill after considering any deductions, co-payments, or inadmissible expense.

How To Make A National Health Insurance Reimbursement Claim?

Whenever a policyholder gets medical treatment in a non-network hospital of National Insurance Company, the reimbursement type of claim settlement applies. According to this process, the policyholder needs to pay for all the medical expenses incurred during hospitalisation and then can raise a claim reimbursement request from the insurer.

Follow the steps given below to raise a reimbursement claim with National Insurance Company:

Step 1: Intimate The Insurance Provider
Inform National Insurance Company about your hospitalisation 72 hours prior to getting admitted, in case of planned hospitalisation, and convey within 24 hours in case of emergency hospitalisation at 1800-345-0330.

Step 2: Avail Medical Treatment
Get the medical treatment at the hospital and pay for the bills. Gather all the medical bills, test reports, discharge certificate, and other relevant documents while getting discharged from the hospital.

Step 3: Submit Claim Documents
Share the duly filled and signed claim request form with relevant documents with the National Insurance Company.

Documents required for National Health Insurance Reimbursement Claim

• Duly completed claim form
• Original bills, payment receipts, discharge certificate signed by the doctor
• Original cash-memo from the pharmacies
• Doctor’s advice to go for any medical diagnosis
• Original payment receipt, investigation test reports etc.
• Surgeon’s certificate related to diagnosis and nature of operation performed
• Any other relevant document required by company or TPA
• First investigation report or post mortem report, if required.

Step 4: Verification of Documents
The TPA or claim settlement team of National Insurance Company will verify your claim form and medical documents. On finding them insufficient, they can ask to provide some more information or documents. If your claim request gets disapproved, you shall be communicated by the insurance provider.

Step 5: Settlement of Claim
On receiving all the documents required, if your claim request gets approved by the insurance provider, all your admissible amounts will be reimbursed after making relevant deductions, co-payments etc.

National Health Insurance Renewal Process

With the renewal process, policyholders can continue to be insured with the health insurance plans of National Insurance Company. While renewing the policies, policyholders can enhance the medical coverage of their health insurance cover. It will help you continue to avail the benefits of your health insurance policy and stay protected against any medical emergency.

Below are the steps to renew your National health insurance policy:

Step 1: Visit the website of National Health Insurance i.e., www.nationalinsurance.nic.co.in

Step 2: Select the ‘Health’ section from the Product tab, then click on the ‘Quick Renewal’ tab

Step 3: Enter the Policy Number and Captcha Code, then click on the ‘Renew Policy’ button

Step 4: Review the details of health insurance plans details and premium amount for renewal

Step 5: Pay for the policy amount online using the payment gateway of the insurance provider.

National Health Insurance Tax Benefits

Holding a National Health Insurance Policy protects your health as well as your savings. Policyholders can get deductions in their taxable income equals to their premium amount according to section 80D of the Income Tax Act. Here are the tax benefit details that you can avail with National health insurance policies:

National Health Insurance Premium Calculation

Some factors affect the premium amount of health insurance policies. Information on such factors can help you choose health insurance plans as per your requirement and budget. Here are the factors, which can impact the premium of the plans of National Insurance Company:

• Age – Policyholders of lower age are charged with lower premium amounts and policyholders with higher age are required to pay for a higher premium. The premium amount of health insurance plans go up with your age as it makes you more prone to illnesses and health complications.
• Sum Insured – Higher the coverage you would purchase, higher the premium amount you will be charged with as it will make the insurer pay for more compensation. Hence, you should choose the sum insured amount according to your health budget and medical requirement.
• Lifestyle and Habits - People with the habit of smoking, drinking or chewing tobacco products on a regular basis are charged with an extensively higher amount of premium for the health insurance plan they opt for than from normal customers. Also, their applications can even get rejected as these habits can make them more vulnerable to illnesses.
• Body Mass Index (BMI) - Policyholders with higher Body Mass Index (BMI) are more susceptible to several health complications such as heart diseases, diabetes, blood pressure and so on. It makes them visit hospitals on a frequent basis. Therefore, they are charged with a higher health insurance premium amount than people with normal BMI.
• Family Medical History – Policyholders who come from a family with some members who are suffering or have suffered from some certain medical ailments such as cancer, heart diseases, etc., are charged with a high premium amount for health insurance policies by the insurance providers. Though it is not your fault, family medical history affects the premium.

National Health Insurance Plan Inclusions

You can avail these inclusions under the health insurance plans of National Insurance Company:

• In-Patient Hospitalisation – The health insurance policy compensates the medical expenses caused due to the hospitalisation of an insured individual for any injury or illness, for more than 24 hours. This feature offers the coverage for room rent, doctor’s fee, diagnostic tests, blood, oxygen, medicines and so on.
• Pre-Hospitalisation and Post-Hospitalisation – With this coverage feature, the health insurance plan tends to cover the expenses incurred due to pre-hospitalisation and post-hospitalization up to 30 days and 60 days respectively for the same injury or illness due to which hospitalisation occurred.
• Day Care Treatment – Under this cover, 140-day care procedures listed in the policy document are insured under the health insurance plan. Basically, these are the treatments or surgeries undertaken with local anaesthesia and due to the advancement of medical science are completed within 24 hours without any hospitalisation.
• Emergency Ambulance – The health insurance policy offers coverage for transportation by emergency ambulance during hospitalisation. Hence, it reimburses 1% of sum insured subject to a maximum of Rs. 2,000 as the ambulance charges for the transportation of an insured member to the hospital during a medical emergency.
• Organ Donor Cover – The coverage of 50% of the sum insured is offered to cover the hospitalisation expense incurred due to the treatment of an organ donor during the organ transplant process. It is applicable only if the insured individual has been medically advised to undergo an organ transplant by a medical practitioner.

What Are The Exclusions of National Health Insurance?

Here are some exclusions under National Health Insurance Plans that cannot be availed by policyholders:

• War Conditions - Medical expenses of any insured member incurred due to the treatment of injuries sustained in war, invasion, riots and other similar conditions.
• Cosmetic or Plastic surgery – Cost of cosmetic or aesthetic procedures of any type or sex change operation is not covered, except for plastic surgery if advised by the doctor.
• Sexually Transmitted Diseases - No medical coverage is offered by the health insurance plans for the treatment of sexually transmitted or venereal diseases.
• Self-Inflicted Injuries - Treatment of injuries or illnesses incurred due to any self-harming action such as suicide or suicide attempt are not covered.
• Drug or Alcohol Abuse - No medical cover is provided for the treatment of injuries or illnesses sustained under the influence of alcohol or drug or any such substance.

The above-given inclusions and exclusion may vary from plan to plan offered by National Health Insurance.