IC-24: Health Insurance
IC-24 examines health insurance as a specialised non-life class: how Indian health products are designed, underwritten, renewed, ported and claimed. Questions often test the interaction of policy definitions and monetary limits rather than recall alone.
Core rules and concepts
- Indemnity cover reimburses actual hospitalisation costs up to the sum insured; fixed-benefit cover pays a stated amount for a listed event and is not measured by the bill.
- A family floater shares one sum insured among insured members; individual cover is separate per person.
- The standard initial waiting period is 30 days except accidental injury; pre-existing diseases, specified diseases and maternity have longer waiting periods. Under the IRDAI (Health Insurance) Regulations, 2016, PED means a condition diagnosed or treated within 48 months before cover, and PED waiting cannot exceed 48 months.
- Sub-limits (room rent, ICU, cataract, modern treatment), deductibles and co-payment reduce the payable amount. Cashless settlement is through network hospitals and TPAs; reimbursement requires bills and discharge records.
- Portability preserves accrued waiting-period credit when switching insurer, if applied before renewal. After 60 months' continuous coverage, the moratorium bars most non-disclosure disputes except fraud and permanent exclusions.
Worked example
Sum insured ₹5,00,000; room-rent cap 1% per day; deductible ₹10,000; co-pay 10%. Hospital bill ₹2,00,000, including room rent ₹8,000 x 5 = ₹40,000. Allowed room rent is ₹5,000 x 5 = ₹25,000, so ₹15,000 is disallowed. Eligible amount = ₹1,60,000 other charges + ₹25,000 = ₹1,85,000. Deductible leaves ₹1,75,000; 10% co-pay leaves ₹1,57,500. The claim is within the sum insured, so payable is ₹1,57,500, ignoring other limits.
Traps
- Applying co-pay before deductible; the order changes the answer.
- Assuming portability resets all waiting periods.
- Treating a fixed-benefit policy as reimbursement.
- Forgetting that the moratorium does not protect fraud or permanent exclusions.