Fine Prints you must watch out while buying a Health Insurance (Mediclaim) Policy

Here is a gist of fine prints which you must watch while purchasing a health insurance policy.

1. No pre existing diseases will be covered. The General Insurance Council of India has adopted a common definition of Pre-existing disease wef 1.6.2008. It defines Pre-existing disease as: “Any condition, ailment or injury or related condition(s) for which you had signs or symptoms, and / or were diagnosed, and / or received medical advice/ treatment, within 48 months prior to your first policy with us.”


2. Thus Pre existing disease includes any disease which has been diagnosed or treated upon within 4 years of first policy with the company. For Eg Mr X was diagnosed with hypertension on 1.5.2005. He takes a health insurance policy from Reliable Insurance Company on 1st of October 2008. Here this will be pre existing disease since he was diagnosed with the disease within 4 years prior to taking the insurance policy.

3. Generally expenses for Treatment of illness/ disease/ sickness contracted by the Insured Person during the first 30 days from the commencement of the policy are not paid under a Insurance Policy. However in some companies this limit may vary. For eg in TATA AIG this limit is 90 days.

4. Most companies do not pay for naturopathy treatment or other modes of treatment other than allopathic.

5. Expenses which are cosmetic in nature are also not paid by many companies.

6. Limits are applied on cost of Ambulance charges.

For Example: Emergency Ambulance Charges for transporting the Insured Person to the Hospital @Rs.600/- per Hospitalisation and Rs.1200/- per Policy period

7. Some companies apply limits on payment of expenses like Doctor’s Fees,Room Rent, cost of medicines. For example the expenses may be limited to percentage on actual expenses or percentage of sum insured.

Some examples:-

* Room rent and boarding @ 1% of sum insured

* ICU expenses per day @ 2% of sum insured

* Fees for Doctor / Surgeon / Consultant / Anesthetist per illness @ 25% of sum insured

* Cost of Drugs and Diagnostic tests @ 50% of sum insured per hospitalization

* Treatments for Cardiovascular Diseases / Cerebrovascular Accident / Cancer and Breakage of Bones : upto Rs.75,000/- where the sum insured is Rs.1,00,000/- and upto Rs.1,50,000/- where the sum insured is Rs.2,00,000/-

* Cataract (both eyes included), up to Rs.15,000/-

* All other Major Surgeries : upto Rs.60,000/- where the sum insured is Rs.1,00,000/- and upto Rs.1,20,000/- where the sum insured is Rs.2,00,000/-

8. In case of post hospitalization some companies limit the amount payable under the policy.

For Example: A lump sum calculated at 7% of the hospitalization expenses is payable towards post-hospitalization, subject to a maximum of Rs.5000/- per occurrence as per the policy Premium

9. Some companies exclude payment of diagnostic expenses and cost of medicines if it is not directly related to disease for which the person is getting treatment.

10. Once a claim is lodged under a Policy the amount of sum insured is reduced by the amount of claim so paid. For Eg A person takes a policy of Rs.1 lakh. He suffers a disease and makes a claim of Rs. 40,000. Now during the rest of the policy period he can claim only upto Rs.60,000 for any other disease that he suffers during the policy period.

11. Some companies limit the amount payable under a policy if the treatment is not taken in the specified hospitals of the insurance company. This condition may vary from company to company.

12. A Insured person can avail Cashless facility in all network hospitals ie he need not make payment for the hospital bills if he is holding a Health ID card issued by the company.

13. However in case of non-network hospitals payment must be made up-front and then reimbursement can be claimed from the Insurance Company on submission of relevant documents.

14. Some companies exclude the following expenses incurred in the first two Years of continuous operation of Insurance cover on treatment Cataract, Hysterectomy for Menorrhagia or Fibromyoma, knee replacement surgery (other than caused by an accident) Joint Replacement. Surgery (other than caused by an accident), Prolapse of intervertebral disc (other than caused by accident), Varicose veins and Varicose ulcers, Cardio-Vascular Diseases, Cancer and Renal complications.

15. Some companies exclude the following expenses incurred during the first year of operation of the Insurance on treatment of diseases such as Benign Prostate Hypertrophy, Hernia, Hydrocele, Fistula in anus, Piles, Sinusitis and related disorders, gallstones and renal stone removal.

16. Many companies exclude all Psychiatric or Psychosomatic disorders from the scope of the cover.

17. Some companies gives discount if the policyholder does not require cashless facility through TPA. They give 6% discount on premium.

18. In most of the companies before issuing a new policy health check-up is compulsory above a certain age from the doctors approved by the insurance company.

19. To ensure that in subsequent renewals medical conditions incepting since the policy was taken do not get excluded, the insuring person must renew the policy without break.

20. Many companies do not pay for congenital external disease, sterility, venereal disease, intentional self-injury, use of drugs, alcohol, rest cure etc

21. Expenses for vitamins and tonics are not paid by many companies unless prescribed for treatment.

22. Many company do not pay for treatment of disease if hospitalization is not required for 24 hours. However some companies pay for technologically advanced treatment that does not require 24-hour hospital stay.

23. Many company do not pay for treatment arising from or traceable to pregnancy, childbirth, including caesarean.

24. Many companies offer cumulative bonus for every claim free year. The sum insured is generally increased by 5% to reward the policyholder for claim free year.

25. In case of domiciliary hospitalization ie treatment in home Pre and post hospitalisation treatment the cost for treatment of following diseases are not payable under a policy

* Asthma

* Chronic Nephritis and Nephritis Syndrome

* Gastro-enteritis

* diabetes mellitus and insipidus

* epilepsy

* hypertension

* influenza

* cough and cold

* all psychiatric or psychosomatic disorder

* pyrexia of unknown origin for less than 10 days

* tonsillitis and URTI

* arthritis

* rheumatism

* Any variation of deficiency syndrome or AIDS

* Convalescence,

* general debility,

* “run-down” conditions sterility,

* venereal disease,

* intentional self-injury

* use of intoxicants

26. Following expenses are not paid by many companies

* Vaccination,

* Inoculation circumcision

* change of life or cosmetic

* aesthetic treatment,

* plastic surgery, unless dental treatment unless requiring hospitalisation necessitated due to accident or as a part of any illness.

* Cost of spectacles, contact lenses, hearing aids.

27. Nuclear perils and war group of perils are not paid by many companies.

28. Routine physicals or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or X-ray examinations except in the course of a disability established by the prior call or attendance of a physician are not paid by most of the companies.


By Dr.Rakesh Agarwal, M.Com(BIM), PGJMC,LLB,FIII,MBA,ACA,Phd

Associate Editor, The Insurance Times Group
25/1,Baranashi Ghosh Street, Near Girish Park, Kolkata – 700007. India

Excerpts from Health insurance in India A Review. Copyright The Insurance Times

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