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Written by Harsh Saini
Content Expert
Written by Ayush
IRDAI-Certified Expert at Pluto
The amount of coverage one needs is not the same for everyone. It depends on your age, stage of your life, income, city and future medical needs.
As a general benchmark, your health insurance cover can be around 50% of your annual income. For example, if your annual income is ₹20 lakh, you may consider a health insurance cover of around ₹10 lakh.
However, this may not be sufficient for everyone, particularly if you live in a city where healthcare costs are higher. For example, a person living in a Tier 1 city may consider a ₹15–20 lakh health insurance cover. In comparison, someone living in a Tier 3 city with relatively lower medical costs may find ₹5–10 lakh of coverage more suitable.
Note: If you have a pre-existing disease, your health needs extra attention. A higher cover with a super top-up can provide additional financial protection when medical costs rise.
|
Feature |
Mediclaim |
Health Insurance |
|
Coverage Scope |
Mainly covers eligible hospitalisation expenses and treatment costs related to an illness or accident |
Offers wider protection that usually includes pre- and post-hospitalisation, daycare, ambulance, wellness care |
|
Coverage Amount |
Usually comes with a lower sum insured and limited choices for increasing protection |
Usually offers higher coverage options, helping you choose protection based on your healthcare needs and rising medical costs |
|
Flexibility |
Offers simpler coverage with fewer choices for changing or adding benefits |
Gives greater flexibility through different coverage options, add-ons, and benefits that can suit changing healthcare needs |
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| Coverage or Expense | Maximum Deduction |
|---|---|
| Self and family | ₹25,000 |
| Self and family + parents below 60 | ₹50,000 |
| Self and family + senior citizen parents | ₹75,000 |
| Self and family + parents (all senior citizens) | ₹1,00,000 |
Purchasing a health insurance plan requires you to submit a few documents that help the insurer confirm your identity, age, address, and health details.
Some insurers may ask for recent passport-size photographs of you and the people included in the policy. However, the exact document list can differ between insurers, so find out what they require beforehand to avoid delays. Lastly, if you already have health insurance, keep your existing policy documents ready when renewing or transferring the policy.
Inform the insurer before planned hospitalisation and share the treatment details to begin the claim process.
Visit the hospital’s insurance desk and fill out the pre-authorisation form with your policy and treatment details.
Submit your policy papers and medical details to the hospital so they can send your claim to the insurer.
The hospital then sends the form and medical reports to the insurer for review and approval.
The insurer checks your claim and approves the amount and pays it directly to the hospital.
Collect all receipts and treatment documents from the hospital, then get the claim form from your insurer and fill it out.
Send the completed form and supporting documents to the insurer within the required time.
The insurer checks your treatment details and submitted documents to decide whether the expenses qualify for reimbursement.
Keep track of updates and provide any additional documents if requested.
Once your claim receives approval, the eligible claim amount is transferred to your registered bank account.
| Possible Reason | What It Means | How You Can Avoid It |
|---|---|---|
| Policy Has Lapsed | Your policy was not renewed on time, so it was inactive when you made the claim. | Keep your renewal date in mind and make sure your policy stays active. |
| Waiting Period Not Completed | The treatment was related to a condition that was still within its waiting period. | Check the waiting periods for different illnesses and treatments before making a claim. |
| Medical History Not Disclosed | Important information about an existing illness, earlier surgery, or medical condition was not shared while buying the policy. | Give complete and honest details about your health when applying for insurance. |
| Claim Form Has Errors | The claim form contains wrong, missing, or unclear information about the patient, treatment or policy. | Read the form carefully and check every detail before submitting it. |
| Treatment Is Excluded | The treatment or medical procedure is not included in your policy’s coverage. | Read the list of exclusions before buying the plan and seeking treatment. |
| Documents Are Missing | Important papers such as bills, discharge summaries, or medical reports have not been submitted. | Keep all original treatment documents safely and check the insurer’s required document list before submission. |
| Claim Was Reported Late | The insurer was not informed about the hospitalisation within the required time. | Inform the insurer within the stated time for both cashless and reimbursement claims. |
| Unnecessary Medical Treatment | The insurer does not find enough medical reason for the hospitalisation or treatment claimed. | Make sure the treatment is recommended by a qualified doctor and supported by medical records. |
| Sum Insured Is Used Up | Your available health cover has already been fully used through earlier claims during the policy year. | Consider additional protection such as a top-up plan if your healthcare needs may require higher coverage. |
| Policy Limit Was Crossed | A specific expense has gone beyond the limit set by your policy, such as room rent or ambulance charges. | Check all sub-limits before choosing a plan so you understand how much can be claimed. |
| Required Share Was Not Paid | You have not paid the required co-payment or remaining deductible amount during the claim. | Check your co-payment and deductible rules so you know how much you must pay yourself. |
| Unproven Treatment | The treatment does not have enough recognised medical evidence or is not accepted under the policy. | Check whether the treatment is recognised and covered before starting the procedure. |
| Self-Inflicted Injury | The claim is related to an injury or illness caused intentionally through self-harm. | Check the policy exclusions carefully to understand situations that are not covered. |
| Details Do Not Match | The patient’s name, date of birth, policy number, or other details differ across submitted documents. | Check that important details are the same across your policy, identity proof, hospital papers and claim form. |
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Here are a few insurance terms that you should know before you purchase a health insurance policy:
Co-payment means that you pay a fixed part of the medical bill while the insurer pays the remaining amount. For example, if your policy has a 20% co-payment and your bill is ₹50,000, you have to pay ₹10,000 while the insurer will pay ₹40,000. The percentage can differ between plans and a higher co-payment implies that you pay more out-of-pocket.
A deductible is a part of an eligible medical bill that the policyholder chooses to bear before their insurer steps in. For example, suppose your hospital bill is ₹80,000 and your policy has a deductible of ₹10,000. You would pay ₹10,000 from your own pocket, while the insurer would cover the remaining ₹70,000. This amount is decided when you purchase the policy and applies as per its terms and conditions.
These are empanelled hospitals that have an agreement with an insurer to provide covered medical services to its policyholders. If you choose one of these hospitals for eligible treatment, you may be able to avail cashless hospitalisation. In such cases, the insurer settles the approved expenses directly with the hospital.
Daily cash is a fixed amount paid for each eligible day of hospitalisation. You can use this money for expenses such as meals, travel, or other daily needs during the hospital stay. The amount, number of days and conditions for receiving this benefit depend on the insurance plan you choose.
The free-look period gives you time to read your new health insurance policy after receiving it. During this period, you can check the coverage, exclusions, waiting periods and other details carefully. If you feel the policy does not match your needs, you may be able to cancel it within this time. This period helps you make a more informed decision.
The limit of indemnity is the maximum amount an insurer will pay for medical expenses. For example, if the limit is ₹5 lakh and your eligible expenses are ₹7 lakh, the insurer will not pay the extra ₹2 lakh. Always check this amount before buying insurance.
Medical consumables are items used during medical treatment in hospitals that are normally used once and then thrown away. Examples include gloves, syringes, cotton, masks, etc. Some health insurance plans cover these items, while most do not include them. In that case, you need to pay these costs yourself.
Migration allows you to move from one health insurance plan to another plan offered by the same insurer. This can be useful when your healthcare needs change and you want a different type of coverage. Depending on the applicable rules, certain benefits earned under the earlier plan may continue after migration.
A moratorium period is a specified period of continuous insurance coverage, after which certain undisclosed health conditions generally cannot be questioned. The purpose is to give long-term policyholders greater protection after maintaining continuous coverage for the required period.
Portability allows you to move your policy from one insurer to another without losing the benefits you earned under your existing policy. Suppose you change insurers for better features. When you port, you retain benefits such as eligible waiting-period credits.
The policy period is the time for which your health insurance remains active. For example, a policy can start on 1 January 2026 and continue until 31 December 2027. This period is important because most limits, bonuses and claims are linked to it and also determine the premium payment timeline.
A policy year refers to the 12-month period beginning from the policy start date. For example, if your policy starts on 15 March 2026, one policy year runs from 15 March 2026 to 14 March 2027. These dates help you know when your coverage starts, when it ends, and when you need to renew the policy.
A sub-limit is a smaller payment limit placed on a particular medical expense even when your overall sum insured is higher. For example, your policy may have ₹5 lakh cover but allow only ₹40,000 for room rent. If your actual eligible room expense is higher, you have to pay the excess amount. This might apply to room rent, specific treatments, etc.
Some treatments may not have enough accepted medical evidence to show that they work effectively. These are often called unproven treatments and are usually excluded from regular health insurance coverage.
A waiting period is the time you must complete before certain medical conditions or treatments become covered under your policy. For example, a plan may have a waiting period for pre-existing diseases or certain listed treatments. During this time, related claims may not be accepted. The waiting period can differ from one condition or plan to another.
A wellness benefit encourages you to take better care of your health instead of waiting until you become sick. Depending on the plan, you receive rewards for activities such as health check-ups, fitness activities or maintaining healthy habits. These rewards may include discounts, points, etc. However, the exact activities and rewards vary among insurance plans.
An air ambulance is a specially equipped aircraft used to take a patient to a hospital when regular transport is not suitable. It is used during serious emergencies when quick medical support is needed. The service can include medical staff and equipment necessary during the journey. Insurance covers this expense under some plans with limits and conditions.
Recovering from a serious illness can take time. During this period, you may incur extra expenses apart from your hospital bills. A convalescence benefit provides a one-time fixed amount to support your finances if the required conditions are met. However, the amount and qualifying period of hospital stay can differ between insurance plans.
Underwriting is the insurer’s process of assessing the level of risk involved in covering an applicant. It may involve reviewing details such as age, medical history, lifestyle and other information provided during the application. Based on this assessment, the insurer decides the terms of coverage and the premium applicable to the policy.
OPD (Outpatient Department) Treatment covers medical care received without being admitted to a hospital. Unlike hospitalisation, OPD care does not require an overnight stay or admission. It includes visits to a doctor, diagnostic tests, routine check-ups and minor procedures.
