Indian Health Insurance for Maternity and Pregnancy

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Maternity health insurance plan or pregnancy insurance is designed to provide coverage for entire maternity-related expenses of a young family who are welcoming a child home, which is the most beautiful thing that can happen to anyone. Maternity insurance is normally available as an add-on with the main health insurance policy.

This insurance policy covers expenses related to both baby delivery options - caesarean or normal delivery. One must ensure to carefully read the terms and conditions of the policy to understand what is covered and what is excluded under their maternity policy. Generally, maternity plans come with high premiums and long waiting periods (upwards of 24/36/48 months, depending on the plan).
matenity plans insurance
According to current reports, the average age of women becoming mothers has risen to between 32 to 35 years in India and as a result, pregnancies are becoming more complicated. Hence women are ensuring they have adequate insurance coverage through a maternity plan to ensure they are financially covered for their pregnancy. Currently caesareans to normal deliveries stand at 65:35 in metro cities. Maternity is a life-altering journey for a women in more ways than one. With rising medical inflation and overall expenditure, childbirth-related expenses have become expensive. Lack of proper financial planning (which includes a health insurance cover) may result in one spending a lot of hard earned savings from their pocket which may overshadow the happiness of being blessed with a baby. According to experts, one should plan well in advance given that maternity health insurance policies, typically have a long waiting period (between 24-48 month), which is important for all prospective buyers of this insurance plan. Given that most insurance companies do not offer maternity health insurance to women who are already pregnant, deeming it as a pre-existing condition, women who wish to take maternity insurance should apply for it before they conceive. Maternity health insurance is, therefore, a critical aspect of a planned pregnancy.
The definition of maternity expense is a part of the IRDAI’s Circular on Standardised Definitions issued in 2013, so all insurers need to follow this uniform definition. It essentially includes any hospitalisation traceable to child birth, and also includes medical termination of pregnancy and pre/post-natal expenses. Maternity expense includes the following expenses :
  • Maternity related hospitalisation – pre-hospitalisation expenses are covered up to 30 days prior to delivery and will also cover post-hospitalisation expenses up to 60 days.
  • Delivery including Pre and post-natal expenses - Maternity insurance covers expenditure related to both caesarean and normal delivery, as well as post-delivery complications for the mother.
  • Hospitalisation costs- This usually includes room charges, nurse and surgeon charges, anaesthetist consultation charges, medical practitioner fees, and emergency ambulance charges.
  • New Born Baby cover (Day 1-90) – Coverage is also extended to infants in case they are diagnosed with a congenital disorder or some critical illness.

6 Things to Keep in Mind About Maternity Insurance in India

While it’s common knowledge that bringing a child into this world is an enjoyable experience, raising a child simultaneously leads to an increase in expenses, including the cost of the pregnancy and childbirth. A steep rise in maternity expenses over the years is forcing couples to look for options to finance this expense, rather than pay for it from their savings and hence insurers have started highlighting the maternity benefit feature in their health insurance policies to younger couples who are planning to start a family. The couple purchasing these policies should fully understand the scope, exclusions and pricing of these policies and also create a separate emergency fund to meet this requirement. Here below are six important things to keep in mind regarding maternity insurance :
Coverage under maternity benefit in India?
While the coverages vary across insurance providers, the general expenses covered are as follows:
  • Inpatient Hospitalisation Expenses.
  • Pre-hospitalization expenses - 30 days & Post-hospitalization expenses - 60 days (room charges, nursing expenses, anaesthetist charges).
  • Delivery expenses (Normal or Caesarean).
  • Pre and post-natal expenses (depends upon the type of delivery - Caesarean or normal).
  • Vaccination of the infant (some cases).
  • Baby cover (if newborn is diagnosed with congenital disorders).
  • Ambulance charges.
Waiting period and sub-limits under the plan
There is a waiting period of between 2 to 4 years (9 months only for Care’s(formerly Religare) Joy plan) before one is eligible to claim a maternity related expense and this varies across insurers. Thus, it is essential to buy maternity cover as early as possible, even if you have no plans of having a baby anytime soon or explore the plan with the shortest available waiting period and plan for the baby post expiry of the waiting period.

Premium Payable
One of the important aspects to remember is that these policies come with a higher than normal premium. However, the reason these premiums are higher than that of a regular health insurance policy where there’s a high possibility of a claim that needs to be covered, maternity insurance covers an 100% certain event/claim.

Exclusions related to Maternity
There are some specific exclusions applicable to the maternity benefit which are :
  • Age of insured for claiming maternity benefit cover is capped at 45 years.
  • Termination of pregnancy within 12 weeks from the date of conception is not covered by the policy.
  • Medical expenses on ectopic pregnancy are not covered under this benefit.
  • Regular check-ups / Consultation fees / Medicine Costs.
  • In-vitro fertilisation and infertility-related expenses.

Cashless Hospitalisation
Once you are evaluating insurance plans for buying a maternity coverage, also keep in mind the cashless hospital network of the insurer since it is important to have a medical centre near you where the birth can be had as a cashless treatment, rather than pay the expenses and get a reimbursement.

Financially planning a Pregnancy
Since it is most likely that there will be a claim for maternity during the course of the policy once the waiting period has been completed, one needs to ensure they have opted for the right sum insured limits that will cover the maternity expenses, without having to spend too much from their pocket. Also, if your or your spouse’s employer group plan covers maternity expenses, claim from that policy without touching your individual policy so as to protect the no-claim bonus.

Benefits Description under Maternity Insurance Plan

Maternity Coverage
The maternity health insurance plan normally covers the following :
  • Maternity related hospitalisation – pre-hospitalisation expenses are covered up to 30 days prior to delivery and will also cover post-hospitalisation expenses up to 60 days
  • Delivery including Pre and post-natal expenses - Maternity insurance covers expenditure related to both caesarean and normal delivery, as well as post-delivery complications for the mother
  • Hospitalisation costs - This usually includes room charges, nurse and surgeon charges, anaesthetist consultation charges, medical practitioner fees, and emergency ambulance charges
  • New Born Baby cover (Day 1-90) – Coverage is also extended to infants in case they are diagnosed with a congenital disorder or some critical illness.
New-born Baby Cover
Medical expenses of your new born from birth till the completion of 90 days. When the 90-day is over, the baby would be covered under the regular policy upon payment of additional premium.

Hospitalization Expenses
In-patient Care (at least 24 hrs of Hospitalization) : If you are admitted to a hospital for in-patient care, for a minimum period of 24 consecutive hours, the insurer pays for everything – from room charges, nursing expenses and intensive care unit charges to surgeon’s fee, doctor’s fee, anaesthesia, blood, oxygen, operation theatre charges, etc.

Day Care (less than 24 hrs of Hospitalization)
Some insurance plans also take care of day-care treatment if your hospital requires hospitalization for less than 24 hours. Your medical expenses are covered along with a defined list of day care treatments.

Pre-Hospitalisation (Up to 30 days)
Examination, tests, and medication – plan covers all expenses related to diagnostics and pre-hospitalization medication.

Post-Hospitalisation (Up to 60 days)
Maternity plans also cover post hospitalization expenses such as cost of follow-up visits, medication, tests and so on.

Ambulance Charges
Getting to the hospital for delivery should be done with utmost care with the best transport facilities. You will get reimbursements on expenses that you incur on an ambulance service offered by the hospital or any service provider, in an emergency situation.

Longer Policy Term (1/23 year policy)
Longer policies equal to fewer procedures and hassles since one doesn’t have to deal with the renewal of the policy every 12 months. There is also a discount offered for purchasing a long term policy.

Claim Settlement
Cashless settlement is available at network hospitals – just present the Health Card at network hospitals across India and avail the cashless service. Alternately , if one have decided to choose a non-networked hospital / opt for a reimbursement claim, pay and submit all relevant documents to the insurance company for reimbursement.

Benefit
Opting for health insurance enables you to avail tax benefits on the premiums you pay towards your health insurance, as per prevailing tax laws under section 80D of the Income Tax Act, 1961.

Free Look Period
If the insured is not convinces about the coverages under their plan, one can apply for a cancellation and refund within this period. If no claim has been made, the insurer will refund the insurance premium received after deducting proportionate risk premium for the period on cover, expenses for medical examination and stamp duty charges, as applicable.

Pre-Policy Medical Checkup (PPC)
Some insurance plans require you to undergo medical tests that help understand your current health and future health needs better, which is free of cost to the applicant.

Guidelines to buy a Health Insurance policy for Women

With so many options available in the market for everything, Finding the ideal health insurance plan can be tough, but here are some things to look out for :

Women Specific benefits : Benefits covering women specific ailments like breast cancer, thyroid, cysts, harmone related disorders are few which have effected women considerably in recent times.

Large Cashless Hospital Network : Ensure timely admission and treatment to the insured apart from quality healthcare at pre approved costs.

Maternity Coverage : If there is a planned pregnancy on the way, this is a benefit one’s policy must have.

Waiting periods : Opt for a plan which has minimal waiting periods for defined illnesses including Critical Illness, Pre existing diseases etc.

Financially Sound Insurer with Transparent Claims process : Choose an insurer with a good claim settlement ratio and a claim process which is simple and transparent.

Right Sum Assured : Health care treatment costs are increasing everyday. So, decide on the optimum sum assured given the financial position one is in, future commitments, number of dependents etc.

Compare Plans : Visit a website like eindiainsurance to compare similar plans, review their coverages, terms & conditions, premium before making a decision.

Exclusions under a Maternity Insurance Plan

A few of the normal exclusions are below, kindly refer to the entire list available as part of the policy wordings:
  • AIDS treatment-related expenses
  • Congenital diseases
  • Pre-existing ailments or injuries diagnosed within 24/36/48 months of the policy commencement
  • Early Termination of pregnancy (within 12 weeks)
  • Doctor’s visit for regular checkups. - The follow-ups, diagnostic tests and doctor’s consultation during nine month of pregnancy are not covered.
  • Non-allopathic treatment costs
  • Expenses related to self-inflicted injuries, drug use or alcohol
  • Dental treatment expenses
  • In-vitro fertilisation and infertility-related expenses

Claims Process for Maternity Plans

Cashless Claims Process

Step 1 Get admitted to any one of network hospitals of the respective insurance companies…you can also call the insurance company/TPA on their Toll Free assistance number. Both these pieces of information are available on eindiainsurance In case of emergency, you can contact the insurance company within 24 hours of admission to the hospital.
Step 2 Your Identification : At the network hospital you will need to show your Health Insurance health card (nowadays insurers issue e-health cards) of the insurance company and valid photo ID*, along with your policy number, to be able to use your insurance. This will give the network hospital the details they need to contact us for the cashless hospitalization process. * - Passport / PAN card / voter’s ID for identification purposes.
Step 3 Hospital sends cashless hospitalization request form to the insurance company with preauthorization request form which has details of medical history, line of treatment and estimated treatment cost.
Step 4 Wherever the information provided in the request is sufficient to ascertain the authorization, the insurer issues the authorization Letter to the network hospital. Wherever additional information or documents are required we will call for the same from the Network hospital and upon satisfactory receipt of last necessary documents the authorization will be issued.
Step 5 Hospital will send us the final request for authorization of any residual amount along with final hospital bill and discharge summary. You will be discharged from the hospital upon receipt of final authorization letter from the insurer. Any inadmissible expenses, copayments, deductions will have to be paid by you.
Step 6 Once the Hospitalization is done, hospital will send the original claim documents to us. The claim will be assessed by us and payment will be made to the network hospital.

Reimbursement Claims Process

Step 1 Contact Toll free Healthline of the Insurance Company / TPA…same is available on https://www.eindiainsurance.com/ Before you seek medical treatment we request that you contact the insurer atleast 48 hours in advance. This will the claims team to help you follow the next few steps. In case of emergency, you can contact the insurer within 24 hours of admission to the hospital.
Step 2 You can avail treatment at hospital and settle all hospitalization expenses. Collect original hospital bill, receipts, discharge summary, investigation reports, pharmacy bills and other documents from hospital at the time of discharge from hospital.
Step 3 You have to download the claim form from the website https://www.eindiainsurance.com/ .Copy of this form is also included in the policy kit provided to you. Submit the claim documents at nearest branch or Corporate office of the insurance company. The documents should be submitted within 15 days from discharge from the hospital.
Step 4 Wherever the information provided in the claim documents is sufficient to ascertain the admissibility of claim, the insurer will approve the claim. Wherever additional information or documents are required , the insurer will call for the same from you and upon satisfactory receipt of last necessary documents the claim will be settled by the insurance company.
Step 5 Upon approval of claim by the insurer, payment of the reimbursement claim will be made to the policy holder either through EFT or through cheque/DD.

FAQs on Maternity Insurance

Maternity Health insurance plans normall have a waiting period that varies between insurance companies, and ranges from 9 months to 72 months (6 years). You can avail the benefits of your maternity health insurance plans only after the completion of this waiting period and provided you have been insured for consecutive policy years.

The ongoing pregnancy will be treated as as a pre-existing condition, and hence coverage will not be provided by the insurer.

Most insurers do not cover the newborn baby from day one until they are 90 days old. From day 91, they can be added to the parent's policy as a new member by paying the additional premium.

Pre and post hospitalization expenses will not cover ultrasound/scan charges or all your visits to the gynaecologist leading upto the birth of the baby. Besides, AIDS treatments, Fertility treatments like IVF, IUI etc. also are not covered. Abortions are also excluded and so are complications arising in the pregnancy which are self inflicted. Consultation Fees and other Routine charges are also excluded.

If the baby is born with an abnormality, deformity, disease or illness, it is termed as a congenital condition and most policies do not offer coverage for such congenital conditions.

Yes, you can purchase a maternity health insurance while you are pregnant. However, the expenditures incurred for the current pregnancy will not be covered by the policy since it will be a pre existing condition. The subsequent pregnancy after completion of the waiting period will be covered under the policy.

Factors that impact the premium payable are Sum Insured, Co Pay %, Age of the Mother, Location.

Yes, all maternity plans cover both Caesarean and normal deliveries. The Sum insured vary for both delivery types.

As in the case of a health policy claim, one must intimate the insurer about the pregnancy assuming that your plan includes the Maternity benefit. And when the insured get hospitalized for the delivery of the baby, you must raise a claim with the insurance company to ensure a cashless coverage can be availed.

No,if the applicant is pregnant at the time of applying for the cover, then coverage for the same will not be available since it will be treated as a pre-existing condition. The maternity benefit is only available if the delivery happens after the waiting period.

It is advisable that you should take maternity insurance when you are ready to start a family, however be aware of the waiting periods to ensure complete coverage.

Maternity health insurance plan covers the following:
  • Maternity related hospitalisation – pre-hospitalisation expenses are covered up to 30 days prior to delivery and will also cover post-hospitalisation expenses up to 60 days.
  • Delivery including Pre and post-natal expenses - Maternity insurance covers expenditure related to both caesarean and normal delivery, as well as post-delivery complications for the mother.
  • Hospitalisation costs- This usually includes room charges, nurse and surgeon charges, anaesthetist consultation charges, medical practitioner fees, and emergency ambulance charges.
  • New Born Baby cover (Day 1-90) – Coverage is also extended to infants in case they are diagnosed with a congenital disorder or some critical illness.

Giving birth to a child is becoming costly day by day due to medical inflation and advances in healthcare. Besides, complications can arise at any time throughout pregnancy especially at the time of childbirth. A maternity coverage provides a financial support for such unforeseen events.

While buying a maternity coverage, you should take care of the waiting period. Only after a waiting period of 2 – 4years, pregnancy related expenses start to get covered under a health plan. Another thing to look out for is the sub limit of the maternity coverage on the total sum insured.

There are some specific exclusions applicable to the maternity benefit which are :
  • Age of insured for claiming maternity benefit cover is capped at 45 years.
  • ATermination of pregnancy within 12 weeks from the date of conception is not covered by the policy.
  • AMedical expenses on ectopic pregnancy are not covered under this benefit.
  • ARegular check-ups / Consultation fees / Medicine Costs.
  • AIn-vitro fertilisation and infertility-related expenses.

No, IVF is not covered in policies that offer maternity benefits.

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