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UPMSP Vocational Insurance study materials
UPMSP Vocational Insurance study resources

UPMSP Vocational Insurance: Health Insurance and Social Security Schemes: Waiting Periods, Moratorium and PM-JAY

UPMSP Vocational Insurance · Work through your exam, one topic at a time.

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Health Insurance and Social Security Schemes: Waiting Periods, Moratorium and PM-JAY

Domain 4 combines health insurance, where product and claim mechanics are technical, with the government social-security schemes a candidate must be able to name and quantify.

Health insurance mechanics

  • Indemnity policies reimburse hospitalisation up to the sum insured; benefit policies pay a fixed amount (hospital cash, critical illness) regardless of the bill.
  • Waiting periods: an initial 30 days (accidents excepted), a specific-disease wait of 1–2 years, and a pre-existing disease wait that cannot exceed 36 months.
  • A condition is pre-existing if it was diagnosed or treated in the 36 months before the policy began.
  • Moratorium: after 60 months of continuous cover the insurer cannot contest a claim except for proven fraud or permanent exclusions.
  • Portability carries accrued waiting periods to a new insurer; migration moves the insured between plans of the same insurer.
  • Cashless claims run through TPAs and the network; the 2024 master circular requires cashless authorisation within one hour and final discharge within three hours.
  • Room-rent or category sub-limits trigger proportionate deduction of the whole bill.

Social security schemes

  • PM-JAY (Ayushman Bharat): ₹5 lakh per family per year for secondary and tertiary hospitalisation, with no limit on family size or age.
  • ESIC: wage ceiling ₹21,000 a month; the employee contributes 0.75% of wages and the employer 3.25%.
  • PMSBY: ₹20 a year, ₹2 lakh accidental death and total disability, ₹1 lakh partial disability, ages 18–70.
  • PMJJBY: ₹436 a year, ₹2 lakh life cover, ages 18–50.

Worked example

Sum insured ₹5,00,000; room-rent cap 1% of the sum insured per day = ₹5,000. The patient takes an ₹8,000 room. The eligible bill is ₹2,00,000. Deduction ratio = 8,000 ÷ 5,000 = 1.6, so payable = ₹2,00,000 ÷ 1.6 = ₹1,25,000, not ₹2,00,000.

Traps

  • Saying a pre-existing disease is payable from day one.
  • Swapping the PMSBY and PMJJBY amounts.
  • Ignoring proportionate deduction in a room-rent question.