Health cover checklist

Read your policy the way
a claims officer eventually will.

Forty-odd points, grouped the way a claim actually unfolds. Tick as you go — progress is saved in your own browser and nothing is sent anywhere. Print it, or send whatever is still unclear straight to WhatsApp.

How to use this

Keep your policy wording open beside it — the schedule page plus the section on exclusions and waiting periods answers most of it. If a point cannot be answered from the document, that is itself the finding. Anything left unticked at the end is a good agenda for a fifteen-minute conversation.

Section 01

Who is actually being covered

Structure decides more than sum insured does. Get the shape of the cover right before arguing about the number.

Every person to be covered is listed by name and date of birthIncluding anyone who joined the household recently. A person not on the policy is not covered, however obvious their membership of the family seems.Floater versus individual has been decided deliberatelyA floater shares one sum insured across everybody — efficient until two people claim in the same year. Individual policies cost more and cannot be exhausted by someone else.Parents are on a separate policy, not added to the family floaterAdding elderly parents raises the premium for everyone and puts the shared sum insured at their risk. A separate senior citizen plan is almost always the better structure.Employer group cover has been mapped, not assumedNote the sum insured, any co-pay or room cap, and what happens when you change jobs. Treat it as a top-up on cover you own, never as the foundation.Anyone with an existing condition is identified up frontThis changes which insurer, which waiting period, and whether a PED-reduction rider is worth buying.

Section 02

How much cover, and on what basis

Start from what a real admission costs at the hospital you would actually use — not from a round number.

A realistic bill has been checked for the hospital you would useAsk what a bypass, a joint replacement or a week in ICU costs at the two or three hospitals nearest you in NCR. Work backwards from that.The sum insured accounts for medical inflation, not just todayMedical costs have compounded well ahead of general inflation. A figure that looks generous today should still look adequate in ten years.A super top-up above the base policy has been consideredThe cheapest way by far to reach a high total cover, because it only engages above a deductible. Usually better value than raising the base sum insured alone.Restoration or reinstatement of sum insured is includedRefills the cover once exhausted in a policy year. Check whether it applies to the same illness or only unrelated ones — the difference is significant.The no-claim bonus terms are understoodHow much is added per claim-free year, the maximum it can reach, and crucially whether accumulated bonus is reduced after a claim.

Section 03

The clauses that decide the payout

This section is the whole game. Everything here can reduce a settlement without the claim ever being called rejected.

Room rent: there is no cap, or you know the cap in rupees per dayNot the percentage — the rupee figure. Then confirm whether exceeding it triggers a proportionate deduction across the entire bill, which it usually does.ICU charges have no separate capSome policies cap ICU separately, and ICU is where large bills are made.Co-pay is either absent or consciously acceptedA 20% co-pay on a ₹8 lakh claim is ₹1.6 lakh from your pocket. Acceptable if you chose it for a lower premium; painful if you discovered it at discharge.Disease-wise sub-limits have been readCataract, knee and hip replacement, hernia and similar procedures often carry their own ceilings well below the sum insured.Consumables and non-medical items are covered, or the gap is acceptedGloves, syringes, PPE and administration charges are routinely disallowed and can be 8–15% of a bill. The consumables add-on is the most useful one in the Indian market.Pre and post-hospitalisation windows are notedTypically 30–60 days before and 60–90 days after. These are claimed separately and are the most commonly forgotten money in health insurance.Day-care procedures are covered and the list has been checkedAnything under 24 hours is only payable if it appears on the day-care list. For a planned procedure, confirm in writing beforehand.Domiciliary treatment and modern treatment methods are includedRobotic surgery, oral chemotherapy and similar are covered by most current policies, sometimes with sub-limits. Worth confirming rather than assuming.

Section 04

Waiting periods and disclosure

The part that is decided years before the claim, and cannot be repaired afterwards.

Every medical fact has been declared on the proposalConditions, medication, past surgeries, hospitalisations, consultations in the last few years. Including the ones that feel too small to mention.You filled the proposal yourself and read it before signingNever signed blank, never left to an agent. Keep a copy with the policy.The initial waiting period is notedUsually around 30 days for illness, with accidents covered from day one.The pre-existing disease waiting period and its end date are written downCapped at three years under current IRDAI norms, but confirm the figure in your own wording.Specified-illness waiting periods are notedCataract, hernia, piles, joint replacement and others usually carry their own waits.Maternity waiting period checked, if relevantTwo to four years is typical, with a sub-limit that may not match actual NCR delivery costs. Only worth it if planned well ahead.The moratorium date is marked on the folderAfter five years of continuous cover under current norms, a claim cannot be contested for non-disclosure except for proven fraud. Protect continuity to reach it.Other existing policies have been disclosedIncluding employer cover. This drives the contribution clause and is a material fact.

Section 05

Hospitals and how a claim will actually run

Worth ten minutes now; worth considerably more during an admission.

The two or three hospitals you would actually use are in network todayCheck by name on the insurer's current list, not by the total count of network hospitals. Recheck at every renewal.The claim intimation number is saved in your phoneInsurer or TPA, saved now. Not something to search for at midnight.You know the intimation deadlinesBefore a planned admission, and within 24 hours of an emergency one.You know what to do if you land at a non-network hospitalSwitch to reimbursement mode from the first day: collect originals, keep prescriptions matched to bills, and note the submission deadline after discharge.Somebody other than you knows where the policy isA spouse, a sibling, an adult child. The person handling admission is often not the person who bought the policy.

Section 06

Cost, renewal and the exit

The decisions that determine whether this policy is still in force in twenty years, which is when you will need it most.

The premium is sustainable at 60 and at 70, not just todayAsk to see the insurer's premium table by age band. A policy you cannot afford at 62 is worth very little, because you cannot switch then.Lifelong renewability is confirmedStandard now, but confirm it in the wording rather than assuming.Renewal date is diarised with two remindersOne a month before, one a week before. A lapse restarts every waiting period from zero.The grace period is knownThe days after the due date in which you can still renew without losing continuity.Portability rights are understoodYou can move insurer at renewal and carry forward waiting periods already served, applying at least 30 days ahead. Never let the old policy lapse before the new one is issued in writing.The exclusions section has actually been readIt is short. It is where the surprises live.The free-look period was used to read the documentCurrently 30 days from receipt to return the policy for a refund net of small charges. It exists precisely for this.

Read your policy the waya claims officer eventually will.

Read your policy the way
a claims officer eventually will.