It is important to understand thoroughly limits, coverage, terms, conditions and exclusions under a health insurance policy before and after purchasing it from an insurer. The key terms in health insurance policies are as follows:

1. Eligibility & Entry Age: Minimum entry age is usually 18 years (for individual policies) and maximum entry age varies (typically 60–75 years; some plans up to 80+). Children are covered from 90 days onwards (sometimes from day 1).

👉 Policies usually offer lifelong renewability, provided renewal is done on time.

2. Waiting Periods:

 (a) Initial Waiting Period is 30 days from policy start date. No claims allowed except for accidents.

 (b) Pre-Existing Disease (PED) Waiting Period is typically 2–4 years.

(c) Disease-Specific Waiting Period is usually 1–2 years, e.g. in case of – Hernia, cataract, Gall bladder stones, Knee replacement, etc.

3. Sum Insured & Sub-Limits

Sum Insured (SI): Maximum amount insurer pays in a policy year

Sub-limits: Caps on certain expenses, such as: Room rent, ICU charges, Specific treatments

👉 If you choose a higher room category during treatment, proportionate deductions on the entire claim amount may apply.

4. Co-Payment Clause: A percentage of claim amount borne by the insured, usually 10%–30%. Common in senior citizen policies.

Example: Claim of ₹2 lakh with 20% co-pay → You pay ₹40,000, Insurance Co. pays ₹1,60,000.

5. Deductible Clause: A fixed amount paid by the insured before insurance kicks in. Common in: Super top-up plans, Group insurance policies.
6. Cashless & Reimbursement Claims

Cashless Claims: Available at network hospitals. Insurer settles bills directly with hospital

Reimbursement Claims: You pay hospital bills first, claim reimbursement later.

👉 Documentation is critical for reimbursement claims.

7. Hospitalisation Definition

Most policies define hospitalisation as: minimum 24 consecutive hours treatment in hospital, except for listed day-care procedures (e.g., cataract, chemotherapy, eye surgery are covered if listed in Policy).

8. Pre & Post Hospitalisation Expenses: Pre-hospitalisation is generally covered for 30–60 days and post-hospitalisation coverage is for 60–180 days. It covers: Diagnostic tests, Medicines & Follow-up consultations.
9. Exclusions (Very Important):

Permanent Exclusions-

• Cosmetic surgery
• Self-inflicted injuries
• Alcohol/drug abuse
• Experimental treatments
• War and nuclear risks, etc.

Temporary Exclusions-

• Pre-existing diseases during waiting period
• Listed illnesses during disease-specific waiting period

Non-Medical Expenses are generally not covered, unless specified like gloves, masks, toiletries, food charges, attendant charges. Some plans now offer consumables cover.

10. Claim Settlement Conditions:

• Timely intimation is mandatory
• Complete documentation isrequired
• Claim may be approved, partially settled or rejected (with reasons)

11. Policy Renewal & Grace Period: Grace period: 15–30 days. Coverage ceases if not renewed within grace period. Continuity benefit is lost if policy lapses.
12. Free-Look Period: 15 days from receipt of policy document. Policyholder can cancel and get refund after deductions.
13. No Claim Bonus (NCB): Increase in sum insured for claim-free years – Usually 5%–50% per year with maximum cap defined in policy.
14. Migration & Portability: You can port your policy to another insurer. Waiting periods already served are carried forward. Must apply 45 days before renewal.
15. Disclosure of Information: Full disclosure of medical history, lifestyle habits (smoking, drinking) as per Proposal Form. Non-disclosure can lead to claim rejection
16. Policy Cancellation: Insurer can cancel for fraud, misrepresentation. Policyholder can cancel anytime (refund as per rules).