Health Insurance 1823 views December 14, 2020

Health Insurance Clauses That You Should Know Before Buying a Policy

Health Insurance comes to your rescue when it helps you clear expensive medical bills arising from the treatment of yourself or any of your family members in a hospital. It ensures cashless treatment when an individual is admitted to a network hospital of the insurer. Whereas if the treatment happens in a non-network hospital, you can spend it by yourself and get that reimbursed from the insurer later. But within the fineprint of a health insurance policy, insurers set certain clauses that most don’t look into and end up cursing themselves when they are about to claim. Either the claim gets rejected or the coverage amount comes less than you would expect. Any of these would defeat the purpose of having a health insurance policy. So, read here some important Health Insurance Clauses before you go on to buy a policy. 

Health Insurance

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So What are Those Health Insurance Clauses That You Should Consider?

Health Insurance Clauses can be regarding claims, their limits, ailments, etc. If you know these beforehand, it will only help you choose the right policy for yourself and your family. So, don’t look at the benefits alone, keep an eye on the clauses too. Let’s read all such important clauses without any further delay. 

Waiting Period 

As the name suggests, the Waiting Period clause means the policyholders need to wait for a while before the cover starts for them. Most health insurance companies will start covering for ailments/diseases after a month from the inception date of the policy, except for the treatment of injuries due to accidents. But the application of ‘Waiting Period’ does not end here! It applies to pre-existing diseases too. Before the policy inception, if you had any diseases, you may have to wait for around 2-4 years before you get covered for the same. However, the Waiting Period clause for pre-existing diseases can vary from one insurer to another. So, choose the insurer that comes with a shorter waiting period if you have any pre-existing illnesses before the commencement of the policy.


This is an important health insurance clause particularly when you are about to claim. With deductibles, it means you need to pay a certain portion from your end first before getting the insurance coverage. Insurance companies can alter deductibles as per illnesses, conditions, and even the medical procedures, etc. You might get a lower premium to pay with deductibles. But should you go for the same ? Yes, some insurance companies offer insurance cover without applying any deductibles. Check the policies of such companies and choose the one for you and your family.  

Co-payment Obligations 

As the name suggests, the payment of healthcare expenses needs to be shared between the insurer and the policyholder. Some insurance companies make co-payment mandatory for policyholders above 55 years or so. Again, policies with a co-payment health insurance clause can be avoided as they could come well short of meeting the rising healthcare expenses. So, pick the policy having a no co-payment clause so that you get adequate cover for such expenses.

Intimation Clause 

At the start, we told you about the cashless treatment at network hospitals of the insurer. But you could miss this facility if you don’t intimate the insurer on time. You need to intimate your insurance company 24 hours before a planned hospitalization and within 24 hours for emergency hospitalization. Failing to do so will mean the rejection of the cashless claim. Yes, you have the option to seek reimbursement later. But if you are tight on budget, the denial of cashless health insurance claims can hit you hard financially. So, don’t ignore this important health insurance clause. And if the network hospital is too far away from your location, you will anyways go for reimbursement claims. Here, you need to send the documents to the insurer within 7-15 days of getting discharged from the hospital. The documents will include medical bills, discharge paper, etc. 


Health insurance companies also state a clause in the fineprint where they describe the limit up to which they could cover. Stuff like room rent, attendant allowance, surgeon’s fees and other expenses are present in the medical bill, but companies may not cover upto the actual amount charged by the hospital with regards to these. So while comparing health insurance policies, check these sub-limits carefully and choose the one that has a ZERO capping or is covering the maximum amount. Also, check the coverage for illnesses and choose a plan that gives you the maximum cover against each of these. 


While we focus on the medical expenses that health insurance companies cover, rarely do we pay attention to what they ‘DO NOT’. Not having an idea of the exclusions could result in an outright claim rejection later. And, if you do not have the savings to match the healthcare expenses, you will only feel aggrieved! So the health insurance policy you choose should have minimum exclusions. 

No Claim Bonus and Sum Insured Restoration

Clauses don’t necessarily come with a word of caution, they come with pleasant surprises too! It again reinforces our point of reading the fineprint carefully. You could fail to maximize benefits like No Claim Bonus (NCB) and Sum Insured Restoration if you don’t read it. With an NCB, you can raise your sum insured if you don’t claim in a year. Most insurance companies raise the sum insured by 5-20% and can do up to 100% too over time. Whereas if you have exhausted the sum insured by claiming a health insurance policy, you can opt for the restoration facility and get the sum insured back to your policy.

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