Top Things To Know Before Buying A Health Insurance Policy For Your Family

by SMCIB on Tuesday, 13 December 2022

Top Things To Know Before Buying A Health Insurance Policy For Your Family

It’s not just about love, but people caring enough to stay up nights, watching out for us. That’s what a family is. A bond like no other. And when it comes to protecting that family, nothing is too much. We work day in and day out trying to provide our loved ones with the comfort that they deserve. And the gift of health surpasses it all.

Every family needs regular health check-ups, treatments for the occasional sickness, and enough financial support to deal with medical emergencies. For all such situations, health insurance is the best protection one can get.

But how do you ensure you’ve got the right policy? Let’s find out, in this article!

Tick these boxes before buying Health Insurance for your family

✅Getting adequate coverage
Health insurance is a long-term investment. This means the policy is going to stay with your family for a lifetime, as long as you duly pay the premiums.

Medical inflation is outpacing regular inflation and it is unlikely that hospitalisation costs fixed for certain treatments will remain the same in the future. Hence, it’s important to factor in an inflation rate of 6 to 8% to ensure the cover is future-ready.

But why be bothered today when your family doesn’t require the cover right now? Can’t you upgrade it later?
Well, with increasing age, you and your family are more likely to be diagnosed with medical conditions. Insurance companies will consider all of you too risky to cover - due to which you may find it hard to get an upgrade.

What if the insurer approves an upgrade with medical conditions?
Then they may increase your premiums, or apply conditions that will limit the coverage.

To sum up, upgrading is a difficult process, and you shouldn’t let your family go through all those complications. So get an adequate cover today, and keep them secured against the future.

✅ Knowing everything the policy covers
You should be aware of the extent of the policy’s coverage, before purchasing it for your family.

Here’s a list of some common expenses that are covered under health insurance -


Scope of coverage

Inpatient care expenses

Inpatient care is the healthcare that you get when you are admitted to a hospital to undergo a particular treatment or surgery due to an illness or injury.

The expenses related to inpatient care will be covered only if your family member undergoes a continuous hospitalisation of 24 hours or more.

Daycare treatment expenses

Daycare treatment is performed in a hospital or a daycare centre under general or local anaesthesia and takes less than 24 hours to complete. The costs of daycare treatments will be covered by health insurance.

Pre and post-hospitalisation expenses

Pre-hospitalisation expenses are those that are incurred prior to hospitalisation, and post-hospitalisation expenses are those that are incurred after getting discharged.

Domiciliary expenses

These include expenses incurred while taking medical treatment at home because -

  1. No beds are available at the hospital, or
  2. Your family member suffers from a serious illness or injury that prevents them from being moved to the hospital.

Organ donor expenses

If customised with an organ donor cover, health insurance will bear the expenses of the organ donor during organ transplantation.

Costs of organ screening, surgery pre-hospitalization and post-hospitalisation recovery, etc. will be covered.

Alternative treatment costs

These treatments don't fall under the umbrella of conventional western medicine.

They are also known as AYUSH treatments and include Ayurveda, Unani, Siddha, Homoeopathy, Naturopathy, etc. and they are covered by some policies.

Road ambulance charges

The cost of transportation from the place of the incident to a nearby hospital, as well as from one hospital to another for better treatment, will be covered.


✅ Understanding the features and benefits
While some features/benefits will be inbuilt, you may have to voluntarily opt for some.

2 features/benefits you should consider while buying a health plan for your family -


No Claim Bonus

A No Claim Bonus is essentially a reward you get from the insurance company for not making a claim under your health insurance plan during a policy year.

Depending on the product, they will either increase your sum insured by a specific percentage or decrease your premium amount.

Restoration Benefit

During a policy year, when the sum insured limit is exhausted, the Restoration Benefit helps refill it.

This can be done either once a year or within the limitations stated in the policy terms.

Both the benefits are good in their own ways, but they also come with certain drawbacks and T&Cs. Make sure you check them before considering any.

✅ Being aware of the financial limits
Many insurers impose certain financial limitations under health insurance plans, but there are also plans without any. So check if the policy you are looking at has financial limits that will restrict your family from using the entire sum insured available. Also, check if there are any core benefits that have separate financial limitations.

An indicative list of financial limits to look out for -

Room Rent Limit

It is the limit up to which the health insurance will cover the per-day hospital room charges.

A room rent limit will affect not only the cost of the room but also your entire hospital bill.


If the policy has a co-pay clause, you will have to pay a certain percentage of the approved claim amount out of your pocket.

The insurance company will then pay the remaining claim amount.

Limits on Core Benefits

If you choose core benefits, like Modern Treatment Cover, Organ Donor Cover, Domiciliary Hospitalisation Cover, etc., the insurer may not cover the expenses incurred under such core benefits up to the sum insured.

They may set limits or put a cap on how much they will cover under these core benefits. If your family incurs any expenses that exceed the limit set by the insurer, you need to pay them out of your own pocket.

Limits on Treatments

There could be specific limits on how much your family can spend on certain treatments. The most common financial limit in the policy is for cataracts, gallstones, hernias, and similar surgeries.


✅ Being aware of policy exclusions
There will be certain conditions or treatments that will not be covered by a health plan. These are known as exclusions. IRDAI has set certain standard exclusions that health insurance plans will not cover at all. Some of these include -

  1. Costs incurred during admission to the hospital only for diagnosis and observation purposes.
  2. Treatment primarily for obesity or to control your weight
  3. Treatment for injuries/illnesses resulting from intoxicants, such as alcohol, drugs, etc.
  4. Change of gender treatment.
  5. Infertility treatment, etc.

In addition to these, the insurance company may also exclude certain diseases/treatments, depending on the product. Additionally, to keep claims under control, health insurance plans do not cover certain medical conditions or treatments for a specific period when you buy the policy. This period is known as the ‘Waiting Period’. Your family will be able to claim for those medical conditions and treatments - only after the waiting period is over.

Please note: Only accidents are covered from day one under health insurance.

3 types of Waiting Periods to look out for -

Initial Waiting Period

Once you purchase a policy, the insurer will apply an initial 30-day waiting period for all treatments, except for accidents.

Pre-existing Diseases Waiting Period

A pre-existing disease (PED) refers to any condition, ailment, injury, or disease diagnosed or treated by a doctor 48 months prior to the date of issue of your health insurance policy.

All health insurance plans impose a waiting period of 2-4 years for PEDs.

Specified Disease/Treatment Waiting Period

The insurer applies a 2 to 4 years waiting period for specific medical conditions and treatments - like hernia, haemorrhoids, chronic kidney disease, spinal disorders, etc.

The list of such illnesses will be mentioned in the policy wording. Make sure you go through them carefully.


✅ Checking the network hospital list for cashless claims
As the name suggests, cashless claims is a mode of claim settlement where you may not have to pay cash for treatment. The settlement of the bills is taken care of directly between the hospital and the insurance company.

Now, for a claim to be covered as cashless, your family member must be treated in a hospital that is on the insurance company's network hospital list. These are the hospitals the insurer has tie-ups with. So while buying the policy, check this list, and whether the ones in your area are on the insurer’s network list and will provide a cashless facility.

✅ Assessing the quality of the insurance company
Before choosing an insurer, check the following aspects -

  1. Claim Settlement Ratio (CSR): It refers to the total number of claims settled in a year by the total number of claims filed in a year. The higher the insurer’s CSR, the better.
  2. How quickly the valid/approved claims are being paid?
  3. The complaints received from other customers.
  4. The ease of the claim settlement process in terms of the form length, documentation, etc.

You can get these details from the public disclosure section on the insurer’s website, your financial advisor, or the IRDAI's website

Wrapping up!

When it comes to the safety of our family, we should settle for nothing but the best. This article aims to decode the nuances of health insurance and make things a little simpler for you. Hope it helps you find a policy that’s right for your loved ones. Because they SO deserve it.

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