A newborn isn’t automatically covered under maternity policy

Published in Mint on 25th Nov 2014, Written by Abhishek Bondia

Are newborns covered under maternity policies? What all does the insurer pay for in such policies and what are the exclusions?
—Methali

Most individual medical insurance plans have a minimum enrolment age of 91 days. So, newborns are not automatically covered. However, most individual plans that offer maternity benefits allow coverage for newborns in their first 90 days as well.

Once covered, the policy works for a newborn in the same manner as for the parents.

Three standard exclusions relevant for newborns are a) congenital diseases, i.e., physical abnormalities present since birth, b) non-medical expenses such as nursery charges, and c) vaccination charges, unless specifically mentioned.

I want to buy a health cover and a critical illness cover. Do you think I should opt for a health plan that comes with a critical illness option built in or buy the critical illness cover separately.
—Ashwin Gupta

A critical illness cover is a good health insurance plan to buy. I prefer stand-alone critical illness plans primarily because they tend to cover more number of diseases and allow a higher sum assured
Buy a plan that covers at least 20 diseases or more. The best plans cover diseases that may not require hospitalization such as stroke, deafness, blindness, loss of speech and Alzheimer’s. Buy a sum assured that is comparable to your main health insurance cover.

Is there a particular time period within which an insurer has to pay the claim? And in case the insurer fails to do so, what action can the insured take?
—Lakshmi

The Insurance Regulatory and Development Authority (Irda) has specified step-wise deadlines for processing and settlement of a general insurance claim for example, home insurance. A snapshot is provided below:

Appointment of surveyor: within 72 hours of intimation.

Submission of surveyor report: 30 days (maximum extension up to 6 months)

Clarifications from surveyor: within 15 days of initial report submission (allowed only once)

Final surveyor report: 21 days (after receipt of clarifications)

Offer of settlement or rejection: 30 days (after receipt of final report)

Payment after acceptance of settlement: 7 days

In case there is delay in payment, the insurer is liable to pay an interest of 2% above bank rate.

If the insurer fails to meet the above deadlines, you can escalate the matter within the internal grievance department of the insurer. If you are not satisfied with their resolution, you have the option of filing a complaint with the insurance ombudsman or regulator.

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