Introduction

Buying insurance is hard, and policy documents are harder. That’s why we created simple case studies to explain common terms, what they mean for you, and whether you really need them.

Let’s start with the most common health insurance item—co-payment.

Co-Payment

You're offered a health plan for ₹7000/year with ₹5L coverage. Add a 20% co-pay, and the premium drops by ₹1800. Sounds great—until an accident costs you ₹2L. You pay ₹40K out-of-pocket. That ₹1800 saving? Not worth it. Co-payments rarely help unless it’s for seniors with pre-existing conditions.

Room rent

Falling sick, you discover your insurance limits hotel rent to 1% of the ₹5 lakh sum insured—just ₹5,000/day. You pick a ₹10,000 room, expecting to cover only the extra ₹5,000/day. But later, you're hit with a ₹25,000 bill—because all in-room services get halved too. Avoid room rent-capped policies.

Disease wise limits

Offered ₹10L cover for just ₹6,000 a year, you trusted a family friend’s advice—until a slipped disc surgery cost ₹4.36L, and the insurer only paid ₹2L. Shocked, you learned about hidden sub-limits on illnesses. Always check for disease-wise caps. Choose health insurance without sub-limits—you never know what illness may strike or when.

Waiting Periods

The scariest part of insurance is the uncertainty—once you apply, insurers dig deep into your medical history. If you have pre-existing conditions, they may impose waiting periods (2–4 years), during which related claims can be denied. Choose a plan with the shortest wait to stay protected.

Pre & Post Hospitalization

One morning, you feel dizzy and visit a doctor. Tests are done, then an MRI leads to hospital admission. You're treated and discharged. The bill totals ₹25,000, but insurance only covers ₹10,000—excluding pre-hospital tests. Always choose a plan that covers expenses before and after hospitalization—ideally 30–60 days each side.

Restoration

You're sipping coffee in a hospital bed on a Sunday, thinking about your three-week stay and the ₹4.88 lakh bill—thankfully covered by your ₹5 lakh insurance. But what about your spouse? The cover’s used up. That’s where restoration benefits help—some policies restore your sum insured, even for the same illness.

Day care Treatments

While playing cards with friends, you suddenly feel a sharp stomach pain. It worsens quickly, and you're rushed to the hospital—diagnosed with appendicitis. Surgery is quick; you're discharged the same day. But your insurer won’t cover it, as daycare procedures aren’t included. Always check your policy.

Domiciliary Expense

A deadly disease spreads. You fall sick but hospitals are full. Home care is the only option—costly, yet your insurer covers it. A rare relief, but you're grateful for this unexpected, life-saving support.

No Claim Bonus (NCB)

Insurers may reward you for staying healthy—like boosting your coverage by 50% yearly for no claims. It’s called a No Claim Bonus, but ensure it’s meaningful—not just clever marketing.

Free Health Checkups

A full-body checkup gives peace of mind, though often overlooked. It costs ₹1,000–₹1,500, but some insurers cover it. Even once every two years is a welcome bonus—not essential, but helpful.

Alternative Treatments

As you near fifty, constant fatigue worries you, though your doctor says it's just stress. A neighbor suggests a government-approved Ayush center. There, experts recommend Panchakarma. It’s costly—₹25,000—but luckily, your health insurance covers Ayush treatments upon hospital admission.

Maternity

You're planning to start a family, and childbirth expenses can be high. Insurance may help, but often at a cost—higher premiums or limited coverage. Some plans only offer it under family policies. In the end, weigh if the benefit is truly worth it.

Doctor Consultations

Everyone visits a doctor yearly, and high consultation fees make insurance seem smart. But insurers know you’ll claim yearly, so they raise premiums or cover only part of costs. OPD benefits sound good, but often, skipping them is cheaper.