Health insurance: the clauses that decide whether your claim is paid
Room rent limits, co-pay and disease-wise sub-limits quietly decide how much of your bill you carry.
Two policies with the same ₹10 lakh cover can pay very different amounts on the same hospital bill. The difference sits in four clauses.
Room rent limits
If your policy caps the room at 1% of sum assured and you take a costlier room, many insurers apply proportionate deduction to the entire bill — surgeon’s fees, ICU charges, everything — not just the room difference. Prefer a policy with no room rent cap; it is the single most valuable feature to pay for.
Co-payment
A 20% co-pay means you carry a fifth of every claim. It lowers the premium meaningfully and is common in senior citizen plans. It is a reasonable trade if you know it is there and have the cash.
Disease-wise sub-limits
Some policies cap cataract at ₹40,000, knee replacement at ₹1.5 lakh, and so on, regardless of the sum assured. Read the schedule, not the brochure.
Waiting periods
Thirty days for illness generally, two to four years for named conditions, and up to four years for pre-existing disease. These start again if you let the policy lapse — which is the strongest argument for renewing on time even in a year you consider dropping it.
Where the corporate policy fails
Employer cover ends with the job, is usually small, and often carries co-pay and room limits. Hold a personal policy alongside it, bought while you are young and healthy so the waiting periods are already served when you need them.
Before you buy
Check the insurer’s cashless hospital list for the hospitals you would actually use, the claim settlement time rather than only the ratio, and whether the policy restores the sum assured after a claim in the same year.