What a health policy actually pays

A family buys a ten lakh health policy and assumes ten lakh is available. Then a hospitalisation happens, the bill is four lakh, and the settlement letter shows two point six. The gap is not fraud. It was written in the policy all along.

Room rent proportionality

If a policy caps room rent at one per cent of sum insured and you occupy a room costing twice that, many insurers reduce every associated charge in the same proportion. Surgeon fees, nursing and diagnostics are all scaled down, not just the room charge. This single clause causes more disputes than any other.

Co-payment

A co-pay clause means a fixed percentage of every admissible claim is borne by you. Senior citizen products frequently carry twenty per cent. It applies whether the claim is fifty thousand or five lakh.

Waiting periods

• Initial waiting period, typically thirty days, for anything other than accident
• Specific disease waiting periods, commonly two years, for a listed set of conditions
• Pre-existing disease waiting period, typically two to four years
• Maternity waiting periods, which are often longer still

Read three pages before you buy

The room rent condition, the co-pay clause and the exclusions list. They occupy less space than the brochure and they determine the entire value of the contract. Everything else is detail.