4 Tips for the smooth Health Insurance Claim.

So in this blog, I will talk about what you should do to extract the maximum value from your policy during claims and come out of the process truly satisfied

One of the biggest reasons for dissatisfaction with claims is a lack of awareness of the policy terms and conditions.

It can’t be stressed enough that every policyholder should read one’s policy document as soon as you receive it and if any terms and conditions are not clear, you should call us up at your insurer to understand more about it.

1. Limits on certain procedures

Your policy will have limits of certain procedures like the maximum price of the room that you can avail of.

Now you might want to go for a higher-priced room and you’ll assume that you can simply pay the difference between the actual rent of the room and the allowable limit. Please don’t do that.

Contact your insurance company before you do something like this. Insurers often treat room up-gradation as a partially payable claim.
In other words, never decide to alter the terms of your insurance contract unilaterally.

2. The minimum hospitalization required is 24 hours

Most health insurance policies require the patient to be admitted for a minimum of 24 hours or more to avail of the policy benefits.

This is a firm rule but excludes a few day-care procedures which will be clearly mentioned in your policy document. So if you were to go to your hospital for a tetanus shot, for example – you won’t be able to file a claim on that basis.

3. Waiting period on certain diseases

The third area you need to pay attention to is your waiting period for certain diseases. A waiting period is a sort of a hibernation period during which any claims made will not be admissible

A good number of consumers are not aware that claims for certain conditions are inadmissible for up to two years.

While these are a handful of conditions but it includes popular ones like tonsils, hernia, cataract, etc. A list of these medical conditions will be available in your policy wordings.

And finally, there is a waiting period on pre-existing conditions where there is a wait of 3 -4 years.

This is another clause that several policyholders are not aware of because they did not read the policy document and leads to dissatisfaction when they apply for claims within the waiting period for pre-existing ailments.

A common problem related to this is that consumers don’t state their pre-existing condition while taking the policy. This generally happens under two circumstances.

One, when consumers allow agents to fill the proposal form on their behalf. Two, when they make the application process very lightly and leave these details accidentally or on purpose.

This is a very difficult situation for the policyholder and the insurer. But because every insurance contract was agreed upon based on good faith, there is every probability a claim will not be admissible in case the declaration made by the policyholder is false or partial.

4. Examine the plan’s co-payments, sub-limits, and exclusions

The fourth area and the last of the key clauses that have a major impact on the claims are limiting conditions like co-payments, sub-limits, and exclusions.


Co-payments are where you will have to pay part of the claim and the insurer will pay part of the claim.

If you have ever made a car insurance claim without having zero depreciation on your car insurance policy, you would have noticed that you had to pay like 30-35 percent of the total bill to the workshop and the insurance company paid the rest.

Similarly, co-payment may be triggered in your health insurance contract in some situations which is why you should read the policy document carefully once you receive it.


The same is true for sub-limits which by definition mean that the insurance contract has a capping on how much is payable for a particular illness.

Sub-limits are used for procedures like cataract, total knee cap replacement, and kidney dialysis. These too will be in your policy document and will go something like Rs 20,000 per eye for cataract removal.


And finally, the exclusions, which becomes the cause of a lot of hardship. Most health insurance policies don’t cover maternity and childbirth, yet a huge number of claims are lodged toward these due to a lack of awareness of policy exclusions.

Other exclusions in the policy include participation in adventurous activities, abuse of intoxicants like alcohol, mental disorder-related ailments, etc.

Some smaller payments are generally not included. Again, most policyholders assume that these expenses are claimable but that is not the case.

Some expenses which are not payable by health insurance include registration and discharge charges, cost of hearing aid, any toiletries, donor screening charges, etc.

Understanding co-payments, sub-limits, and exclusions are a must to ensure you are claiming for the right procedures as contracted under your health insurance contract.

The secret to a happy claims experience is to have a clear understanding of what is claimable and what is not under the terms of your policy – most of which are available in the policy wordings. This includes inclusions, exclusion, waiting period, sub-limits, etc.


If you are thorough in your research, you wouldn’t have to worry about claim rejection. And when you know what is in your policy, then it also gives you the necessary knowledge to fight for any unjust calls made by the insurer’s claims team.

Share on social media