Health emergencies can be disastrous not only to your physical condition but to your finances as well. Health Insurance is one of the growing insurance products meant to cover cost of hospital treatment for sickness or accidental injury to the insured.
Following are some of the health insurance policies being offered by the insurers.

  • Individual Health Insurance
  • Family floater Health Insurance
  • Top up Health Insurance/ Super Top Up

In addition to above, insurers do offer certain disease based insurance plans both on reimbursement / benefit policy basis. Coverage and exclusions under the policies may vary from one form/insurer to another but are broadly guided by the health regulations issued by IRDAI from time to time.

Some of the terms
used in Health Insurance

Sum Insured

Sum Insured is the total limit of liability of the insurer under the policy during the policy year.  


Sickness or bodily injury which requires treatment in a nursing home or hospital. Domiciliary treatment does not fall within the policy coverage except for those which are normally treated in a hospital but for specific reasons treating doctor has recommended domiciliary treatment. To claim benefit under the policy for hospitalisation minimum period of stay in hospital needs to be 24 hours.

Cumulative Bonus

Cumulative bonus is increase in sum insured by a percentage allowed by the insurer at the time of renewal for a claim free policy year.

Pre and Post Hospitalisation Expenses

Expenses incurred during a certain number of days prior to hospitalization and post hospitalization expenses.

What is paid under the Policy

Following health treatment expenses are paid under health insurance subject to limits and conditions as specified in the policy.

  • Room, Boarding Expenses
  • Nursing Expenses
  • Fees of Surgeon, Anesthetist, Physician, Consultants, Specialists
  • Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines, Drugs, Diagnostic Materials, X-ray, Dialysis, Chemotherapy, Radio Therapy, Cost of Pace Maker, Artificial Limbs, Cost of Organs and Similar Expenses.

What is not paid under the Policy

The following are generally excluded under health policies. The actual exclusions may vary from product to product and company to company. In group policies, it may be possible to waive / delete the exclusions on payment of extra premium.

  • All pre-existing diseases (the pre-existing disease exclusion is uniformly defined by all non-life and health insurance companies).
  • Under first year policy, any claim during the first 30 days from date of cover, for sickness / disease. This is not applicable for accidental injury claims.
  • During first year of cover cataract, Benign prostatic hypertrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal diseases, Fistula in anus, piles, sinusitis and related disorders.
  • Circumcision unless for treatment of a disease
  • Cost of specs, contact lenses, hearing aids
  • Dental treatment / surgery unless requiring hospitalization
  • Convalescence, general debility, congenital external defects, V.D., intentional self-injury, use of intoxicating drugs / alcohol, AIDS, Expenses for Diagnosis, X-ray or lab tests not consistent with the disease requiring hospitalization.
  • Treatment relating to pregnancy or child birth including caesarean section
  • Naturopathy treatment.

Cashless Settlements

To order to provide convenience and to remove hardship in paying huge hospital bills by the insured most of the insurers have tie-up arrangements with a network of hospitals in the country. In the event of medical condition requiring hospitalisation, insured may seek admission in these networked hospitals. Insurer directly or through their TPA make settlement of claim to the hospital subject to expenses more than limits paid by insured. All other claims are settled on reimbursement basis i.e Insured needs to settle first with the hospital and seek reimbursement on submission of claim to insurers.


The IRDAI introduced health insurance portability in 2011. Through portability, a policyholder can carry forward the credit accrued for pre-existing conditions along with time-bound exclusions while switching from one insurance provider to another, or from one health insurance plan to another. The policyholder also qualifies for getting all continuity benefits, like free medical check-ups and no-claim bonus, which were acquired during the previous insurance policy.

Rights of the policyholder for porting a Health Insurance

Under the health insurance portability scheme, the IRDAI gives policyholder the right to port a policy (individual or family) from a general insurance provider to a specialised health insurance provider, and vice versa. The new insurer is liable to provide him or her a health policy of at least the sum insured under the previous policy. Moreover, the new insurer is also liable to provide the credit associated with the pre-existing conditions that the policyholder had already accrued with the previous insurer. Both the previous insurer and the new insurer are liable to complete the process of porting within the stipulated timeline prescribed under the regulatory guidelines of the IRDAI (Protection of Policyholders’ Interests).

Conditions for porting a Health Insurance Policy

A policyholder can apply for porting a health insurance policy only at the time of renewal, which ensures that the new period of insurance will be effective with the new insurer. Any policyholder can apply for the portability of his/her existing health policy only if it is maintained without any break. To port an insurance policy, the policyholder has to submit a written application to its present insurance company to shift the policy to a new insurer. The application should be made at least 45 days prior to the policy renewal date, mentioning the name of the insurance company to which the policyholder wants to switch his/her policy.

Process of porting a Health Insurance Policy

Once the insurance company receives the insurance portability application, it provides the policyholder with a proposal form and a portability form. The present insurer then shares the details of the insured person with the new insurer via a common IRDAI portal for sharing customer data. Once the new insurance company gets all the details, it has to take a decision about underwriting the insurance policy within 15 days. Failing to respond within 15 days will force the insurer to accept the portability application.