Terms and Conditions of Health Insurance


Health insurance today is a necessity for every person and family. The requirement and ideal policy coverage are dynamic and change with the passage of time. A typical cycle would be as:

  • You purchase an individual policy for yourself when you start working
  • Upon getting married you look for health insurance plans for family, a family floater
  • You add your children to the family floater plan
  • As you grow older you purchase a senior citizen plan to cater to the needs of your advanced years.

There are several different types of health insurance policies available. The health insurance features offered changes from policy to policy and it is imperative that you read the terms and conditions of your policy carefully to avoid rejection of your claim.

What to Look for in the Terms and Conditions of a Health Insurance Policy?

What is health insurance? Ultimately it is a contract which needs careful attention. You need to understand the following most important terms and conditions of your policy:

  • Type of health insurance policy
  • Coverage of the policy and scope
  • Premium payable
  • Standard exclusions
  • Network hospital list
  • Sub-limits and deductibles
  • Limit on number of claims in a policy term
  • The clause on Pre-Existing Diseases, etc.

Other Factors to Check in the Terms and Conditions

Check the following clauses:

  • Sum Insured:
    Buy a policy that comes with sufficient coverage in terms of the sum insured. You need a substantial amount for a family floater as all the members will be sharing it, or if you have pre-existing diseases where the treatment of a specific disease may be expensive.
  • Claim Process:
    The whole objective of purchasing a health insurance policy is to get your claims covered. Look for an insurer that has a record of faster and smoother claim settlement.
  • Network Hospitals:
    Check for your insurer’s list of network hospitals. Cashless facilities are available only at network hospitals and are an extremely important benefit during an emergency.
  • Waiting period:
    All health insurance policies have standard waiting periods. An initial waiting period of 30 days is applicable, maternity has a waiting period of between 2 to 6 years and pre-existing diseases have a waiting period of 4 years.  Buy a policy which offers fewer waiting periods or one which comes with an optional add–on to reduce the same.
  • Co-Payment clause:
    Some policies require you to pay a predetermined percentage of the expenses out of pocket. Your financial burden will increase during emergencies if your policy has a higher co-payment clause.
  • Lifelong Renewability:
    Choose a policy that lets you keep renewing it for as long as you live to remain covered continuously.

Types of Health Insurance Plans

Different policies serve different purposes. The following are the different types of plans available:

  • Individual policy: These provide cover for one individual only. May be basic or comprehensive in coverage.
  • Family floater: A single policy covers all the members of the family with the sum insured being shared amongst them.
  • Group Mediclaim: Purchases by companies for their employees or for specific groups with a common factor between the members.
  • Senior Citizen: Policies with better coverage for conditions which may crop up due to advancing age. Usually, the premiums are slightly higher to accommodate higher benefits for older people.
  • Critical Illness Plan:
    High-sum insured and one-time lump sum payment in case the policyholder is diagnosed with any life-threatening critical illness.

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What do Health Insurance Plans Cover?

The common expenses covered by a health insurance policy depending on the terms and conditions are:

  • Hospitalisation expenses
  • Pre and Post – Hospitalisation expenses
  • Day care expenses
  • Doctor’s and surgeon’s fees
  • Room rent
  • Maternity and New Born expenses
  • Health Check Up, etc.


Given the number of terms and conditions associated with a health insurance policy, it is crucial that you read them and the fine print both when choosing a policy to buy and also after you purchase a policy.

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