HEALTH INSURANCE FAQS

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Health Insurance FAQs

Health Insurance: 50 Detailed FAQs (2025)

Health insurance is a contract between you and an insurer where the insurer agrees to pay for your medical expenses, such as hospitalization, surgeries, and treatments, in exchange for a premium. It helps protect you from high healthcare costs and ensures access to quality medical care. Health insurance can be purchased for individuals, families, or groups, and may include additional benefits like cashless hospitalization, preventive check-ups, and coverage for critical illnesses, depending on the policy chosen.
Health insurance is crucial because it protects your finances against unexpected medical expenses, which can be substantial in the event of serious illness or accident. It ensures you receive timely and quality healthcare without depleting your savings. Additionally, it provides peace of mind, access to a wide network of hospitals, and tax benefits under Section 80D of the Income Tax Act. Early purchase also secures lower premiums and better coverage, especially before the onset of any health conditions.
There are several types of health insurance plans: Individual plans cover one person, family floater plans cover the whole family under a single sum insured, senior citizen plans cater to those above 60, critical illness plans provide a lump sum on diagnosis of specific illnesses, and top-up/super top-up plans offer additional coverage beyond a threshold. Group health insurance is typically provided by employers, and disease-specific plans target ailments like cancer or diabetes.
A family floater policy covers multiple family members under a single sum insured, allowing any member to utilize the total coverage as needed. This is cost-effective compared to buying individual policies for each member. Typically, it covers self, spouse, dependent children, and sometimes parents. Claims can be made by any insured member, and the sum insured is shared, making it ideal for families with varying healthcare needs.
Pre-existing diseases are medical conditions, illnesses, or injuries that you had before purchasing the health insurance policy. Examples include diabetes, hypertension, asthma, or heart disease. Insurers require disclosure of such conditions during application. Coverage for pre-existing diseases is usually subject to a waiting period (often 2-4 years), after which claims related to these conditions are allowed. Non-disclosure can lead to claim rejection or policy cancellation.
A waiting period is the time during which certain claims are not admissible after the policy starts. Common waiting periods include: 30 days for most illnesses (except accidents), 2-4 years for pre-existing diseases, and 1-2 years for specific ailments or procedures. This mechanism prevents misuse of insurance for planned treatments and helps insurers manage risk.
Most insurers allow entry up to age 65, although some policies cater to senior citizens above this age. Children can be included from 90 days old, and dependent children are typically covered up to 25 years. Once issued, most policies offer lifelong renewability, provided premiums are paid on time.
Yes, children can be included in family floater policies from as young as 90 days old. They are considered dependents, usually up to 18 or 25 years, depending on the insurer. Once they exceed the age limit, they need to be moved to an individual policy.
The best time to buy health insurance is as early as possible, ideally in your 20s or early 30s. Younger buyers pay lower premiums, face fewer exclusions, and complete waiting periods before health issues typically arise. Early purchase ensures comprehensive coverage and financial security.
A cashless facility allows you to receive treatment at network hospitals without paying upfront. The insurer settles the bill directly with the hospital, subject to policy terms. You must inform the insurer or TPA and get pre-authorization for planned treatments. For emergencies, intimation should be given within a stipulated time.
Network hospitals have agreements with insurers to provide cashless treatment. Non-network hospitals require you to pay upfront and later claim reimbursement. Always check your insurer’s list of network hospitals for convenience and cashless benefits.
The sum insured is the maximum amount your insurer will pay for medical expenses in a policy year. It’s crucial to choose an adequate sum insured based on age, family size, location, and healthcare inflation to avoid out-of-pocket expenses.
Premiums are determined by age, sum insured, health status, policy type, add-ons, and sometimes location. Older individuals and those with pre-existing conditions usually pay higher premiums. Family floater plans are generally more economical for families.
The free-look period is a window (typically 15-30 days) after policy issuance during which you can review the terms and cancel the policy for a refund, minus nominal charges, if unsatisfied with the coverage.
Medical check-ups are usually required for applicants above a certain age (often 40 or 45) or those with health issues. The insurer may bear the cost or reimburse it if the policy is issued.
A critical illness plan pays a lump sum if you are diagnosed with specified serious illnesses like cancer, heart attack, or stroke. This payout is irrespective of actual treatment costs and can be used for medical or non-medical expenses.
Some plans cover maternity and newborn expenses, typically after a waiting period of 2-4 years. Coverage includes delivery, pre- and post-natal care, and sometimes vaccination for the newborn. Premiums for such plans are usually higher.
Exclusions are conditions or treatments not covered by the policy, such as self-inflicted injuries, cosmetic surgery, dental and vision care (unless hospitalization is required), injuries due to alcohol or drug abuse, and congenital disorders. Always review the policy document for a complete list.
A deductible is a fixed amount you pay before the insurer covers the rest. Co-payment is a percentage of the claim amount you must bear. These features lower premiums but increase your out-of-pocket expenses during claims.
You can make multiple claims in a year, but the total payout cannot exceed the sum insured unless the policy has restoration benefits or other special features.
NCB is a reward for not making any claims in a policy year, often provided as an increase in sum insured or a discount on renewal premium. It incentivizes healthy living and prudent claim behavior.
Restoration benefit reinstates the sum insured if it is exhausted during the policy year, usually for unrelated illnesses. This ensures continued coverage for multiple hospitalizations in a single year.
Typically, you need the claim form, policy copy, hospital bills, discharge summary, investigation reports, prescriptions, and identity proof. For cashless claims, pre-authorization from the insurer or TPA is also required.
Inform the insurer/TPA before admission (for planned treatment) or within a specified time for emergencies. Submit required documents at the network hospital. The insurer settles the bill directly, subject to policy terms.
Pay the bills at the hospital, collect all necessary documents, and submit them to the insurer for reimbursement. The insurer reviews the claim and reimburses eligible expenses as per policy terms.
You get a grace period (usually 15 days) to pay the premium. If not renewed within this, the policy lapses, and you lose continuity benefits like waiting periods and no-claim bonuses.
Yes, premiums paid for health insurance qualify for tax deductions under Section 80D of the Income Tax Act. Limits are higher for senior citizens. Premiums paid for parents’ policies are also eligible.
Yes, you can port your policy at renewal without losing accrued benefits like waiting periods and no-claim bonuses, subject to IRDAI guidelines and acceptance by the new insurer.
AYUSH coverage includes alternative treatments under Ayurveda, Yoga, Unani, Siddha, and Homeopathy, if specified in the policy. Many insurers offer this as a standard or optional benefit.
Some plans offer OPD coverage as an add-on, covering doctor consultations, medicines, and diagnostic tests. Standard policies usually cover only hospitalization unless OPD benefit is specifically included.
Dental and vision expenses are generally excluded unless hospitalization is required due to an accident or major surgery. Some plans offer limited coverage as an add-on or under wellness benefits.
Top-up and super top-up plans offer additional coverage beyond a certain deductible. Top-up plans cover single large claims, while super top-up plans cover multiple claims above the deductible, making them cost-effective for high medical expenses.
Yes, NRIs and foreigners residing in India can buy health insurance, but coverage is limited to treatment within India. Some plans may have specific eligibility criteria or documentation requirements.
Standard policies usually cover treatment within India. Some high-end plans offer limited international coverage for emergencies or specific conditions. Always check policy terms for global coverage.
Many policies offer free preventive health check-ups after a specified period (e.g., every 1-4 years). This encourages early detection and management of health issues and may be linked to claim-free years.
Many insurers allow monthly, quarterly, half-yearly, or annual premium payments. However, some benefits may only be available if the full annual premium is paid upfront.
For cashless claims, the hospital is paid directly. For reimbursement, the nominee receives the amount. If there is no nominee, legal heirs may claim the amount after due process.
If the policyholder dies, the policy ceases for that individual. In a family floater plan, coverage continues for surviving members, subject to policy terms. Nominees can claim any eligible reimbursement.
Permanent exclusions are conditions never covered (e.g., AIDS, cosmetic surgery). Temporary exclusions, like cataract or hernia, are not covered for a specified period (e.g., 1-2 years) but are included later.
Yes, you can cancel during the free-look period for a full or partial refund. After this, cancellation is possible with a pro-rata refund, subject to no claims being made during the policy period.
Domiciliary hospitalization refers to treatment at home due to inability to move the patient to a hospital or lack of hospital beds. It is covered under certain conditions and for specified illnesses.
Alternative treatments like Ayurveda, Unani, Siddha, and Homeopathy (AYUSH) are covered if specified in the policy, usually up to a certain limit and in recognized hospitals.
An endorsement is a change or addition to the policy, such as adding a family member or updating details. Endorsements can be made during the policy period, subject to insurer approval.
Yes, you can buy multiple policies and claim proportionately from each or exhaust one before claiming from another. This can help cover higher medical expenses.
Yes, a grace period (usually 15 days) is provided after the due date for premium payment. If not paid within this period, the policy lapses, and coverage ceases.
Health insurance covers medical expenses due to illness or injury. Life insurance pays a lump sum to beneficiaries on the policyholder’s death or maturity of the policy.
A TPA is an intermediary appointed by insurers to process claims, coordinate with hospitals, and provide cashless services. They play a crucial role in claim settlement and customer support.
Compare plans based on coverage, exclusions, network hospitals, premium, claim process, and customer reviews. Choose a plan that fits your health needs and budget, and review policy documents carefully.
A proposal form is the application document where you provide personal, health, and lifestyle details required by the insurer to assess risk and issue the policy. Accurate disclosure is essential.
Yes, you can claim from multiple insurers. You can either claim the entire amount from one insurer and the balance from another or claim proportionately, as per the sum insured with each insurer.
  • Pre-existing diseases: Not covered during the waiting period (usually 2-4 years).
  • Self-inflicted injuries: Injuries caused by intentional self-harm or suicide attempts are excluded.
  • Injuries due to alcohol or drug abuse: Claims arising from substance misuse are not covered.
  • Congenital disorders: Birth defects or congenital diseases are generally excluded, unless specified.
  • Cosmetic treatments: Procedures for aesthetic purposes (e.g., facelifts, liposuction) are not covered, except reconstructive surgery after accidents.
  • Dental, vision, and hearing treatments: Excluded unless hospitalization is required due to an accident or major surgery.
  • Maternity and infertility treatments: Often excluded or covered after a long waiting period and with sub-limits.
  • Mental illness: Some policies exclude psychiatric and mental health conditions, though recent regulations are making coverage more common.
  • HIV/AIDS and sexually transmitted diseases: Generally excluded from coverage.
  • Alternative treatments: Not covered unless specified under AYUSH benefits.
  • War, nuclear, or chemical contamination: Claims arising from such events are excluded.
  • Experimental or unproven treatments: Procedures not recognized by medical science are not covered.
  • Participation in hazardous activities: Injuries from adventure sports or illegal acts are excluded.
1. 30-Day Initial Waiting Period
Most health insurance policies have an initial waiting period of 30 days from the start date, during which claims (except for accidents) are not admissible. This means you cannot claim for any illness or planned hospitalization within the first 30 days of policy inception. This clause prevents misuse of insurance for planned or anticipated treatments and helps insurers manage risk.

2. 2-Year Waiting Period for Specific Diseases
Many policies have a 2-year waiting period for certain specified diseases and procedures, even if they are not pre-existing. During this period, claims for these conditions are not covered. The list of such diseases varies by insurer but commonly includes:
  • Cataract
  • Hernia
  • Stone in urinary system (kidney/ureter/bladder)
  • Joint replacement (non-accidental)
  • Benign prostatic hypertrophy (BPH)
  • Varicose veins and ulcers
  • Sinusitis and related ENT disorders
  • Gall bladder stones
  • Fissures, fistula, hemorrhoids (piles)
  • Certain tumors and cysts
  • Osteoarthritis and osteoporosis
  • Gastric or duodenal ulcers
  • Hydrocele
  • Chronic renal failure and dialysis
This waiting period is designed to prevent individuals from buying insurance only when they anticipate expensive treatments. After the 2-year period, these conditions are covered as per policy terms. Always check your policy’s list for specifics, as it may vary.
Last updated: Saturday, May 10, 2025