Health insurance deep dive

Individual cover gives each member their own SI. A family floater shares one SI across the family: cheaper, but it can run out. Senior citizen plans are built for people over 60. Group policies are bought by employers for staff.

ExampleA family of three with a ₹10 lakh floater: if the father uses ₹7 lakh, only ₹3 lakh is left for the others that year. On the Calculators tab this family (ages 34, 31 and a child) pays ₹15,232 a year.

Arogya Sanjeevani is a standard product that every insurer offers with the same wording. A top-up pays above a deductible on each claim; a super top-up pays above a deductible on the year's total claims. Critical illness pays a lump sum on diagnosis, and hospital cash pays a fixed daily amount.

Example₹5 lakh base policy plus a super top-up with a ₹5 lakh deductible. Two claims of ₹4 lakh in one year: the base pays ₹5 lakh, and the super top-up pays the remaining ₹3 lakh.

Portability lets a customer move to another insurer at renewal without losing credit for waiting periods already served, but only up to the old SI. Any extra SI starts its waiting periods again.

ExampleAfter 2 years on a ₹5 lakh policy, a customer ports to ₹10 lakh with a 3-year pre-existing disease wait. One year is left on the first ₹5 lakh; the extra ₹5 lakh has the full 3 years.

Age is the biggest factor, because hospital use rises sharply after middle age. Metro cities (zone 1) cost more because treatment costs more. A deductible or co-pay lowers the premium by making the customer share claims.

ExampleIn the health calculator, change the eldest adult's age from 34 to 55 and watch the base premium rise.

Low-risk proposals issue automatically. Anything outside the rules goes to an underwriter, often with medical tests at a diagnostic centre paid for by the insurer.

ExampleA couple aged 40 and 38 with no medical history and ₹10 lakh SI is issued online in minutes. If one declares diabetes, the case moves to medical tests.

The underwriter can accept at standard rates, add a loading (extra premium), add conditions such as a specific exclusion, offer different terms such as a lower SI, or decline.

ExampleA proposer with controlled high blood pressure is accepted with a 15% loading on the premium.

Insurers can no longer refuse a new customer only because of age, although age can still affect the premium, tests and terms offered.

ExampleA 70-year-old applies for a new policy. The insurer may ask for tests or offer a senior plan with a co-pay, but cannot refuse on age alone.

Conditions declared at proposal can be excluded only for a limited time. Named conditions with their own waiting period, such as cataract or hernia, are capped at 3 years too.

ExampleDiabetes declared on a policy starting in 2026 is covered from 2029 at the latest.

After 5 years of continuous cover, the insurer cannot contest a policy or claim because something was not disclosed, unless it can prove fraud.

ExampleIn year six, the insurer finds the customer had a thyroid condition before buying the policy. It must still pay the claim unless it can prove deliberate fraud.

The clock starts when the hospital sends the request. If discharge authorisation takes longer than 3 hours, extra charges the hospital raises for the delay are paid by the insurer, not the patient.

ExampleThe hospital requests discharge at 11:00 and the insurer authorises it at 16:00. The extra hospital charges for that delay fall on the insurer.

Inpatient AYUSH treatment (Ayurveda, Yoga, Unani, Siddha, Homeopathy) is covered up to the sum insured like any other treatment. Insurers need IRDAI approval before raising a senior citizen's premium by more than 10% a year.

ExampleA 68-year-old's ₹40,000 premium can rise to at most ₹44,000 at renewal without IRDAI approval.

Remote consultations are covered on the same basis as in-person ones, and insurers must keep their lists of cashless hospitals current on their websites.

ExampleBefore planned surgery, a customer checks the insurer's website to confirm the hospital is still in the cashless network.

The hospital insurance desk sends the diagnosis and estimated cost. The insurer or TPA approves an amount, which can be raised later. At discharge, the final bill is checked and settled directly with the hospital.

Example₹80,000 is pre-authorised at admission, increased to ₹1.1 lakh after an extra procedure, and the final bill is settled with the hospital at discharge.

The customer pays the hospital, then sends the claim form, bills, discharge summary, test reports and prescriptions. Expenses before and after hospitalisation are usually claimed this way too.

ExampleMedicines bought in the 60 days after discharge are claimed with the doctor's prescriptions and pharmacy bills.

NHCX, under the Ayushman Bharat Digital Mission, uses FHIR-format messages so hospitals and insurers can exchange claims through one channel. Adoption is advised by IRDAI but not legally mandated.

ExampleInstead of logging into a different portal for each insurer and TPA, a hospital sends one standard pre-auth message through NHCX and receives the decision the same way.

If a policy caps room rent and the patient chooses a dearer room, many room-linked charges such as doctors' fees and nursing are cut in the same proportion. Medicines and implants are not cut this way.

ExampleRoom rent limit ₹5,000 a day, room taken at ₹10,000. Room-linked charges are paid at 50%, so the customer can face a large shortfall on an otherwise covered bill.