Core Benefits: The Non-Negotiables
1. In-Patient Hospitalisation
- Room and board charges (ICU, general ward, single room)
- Surgeon's and anaesthetist's fees
- Nursing charges
- Medicines and medical consumables during the stay
- Diagnostic tests during hospitalisation
2. Day-Care Procedures
- Plans should cover 100+ procedures including cataract, tonsillectomy, hernia repair
- Chemotherapy, dialysis, radiotherapy, angioplasty
- Dental procedures due to injury
3. Pre and Post-Hospitalisation Expenses
- Pre-hospitalisation: diagnostics, consultations, medicines before admission
- Post-hospitalisation: follow-ups, medicines, tests after discharge
- Standard: 30 days pre / 60 days post. Better plans: 60/90–180 days
4. Ambulance Cover
- Emergency ambulance charges covered (typically Rs. 1,500–5,000 per hospitalisation)
- Premium plans may cover air ambulance in critical situations
Enhanced Benefits: What Distinguishes a Good Plan
5. Cashless Hospitalisation
At any network hospital, the insurer settles directly with the hospital. You pay only amounts above the policy coverage — co-pay, excluded items, or amounts above sum insured.
6. No Claim Bonus (NCB)
If you make no claims in a policy year, your sum insured increases at no additional cost.
| Claim-Free Years | Starting Sum Insured | NCB (at 10%/year) | Effective Coverage |
|---|
| Year 0 (Start) | Rs. 10 Lakhs | — | Rs. 10 Lakhs |
| Year 1 | Rs. 10 Lakhs | +10% | Rs. 11 Lakhs |
| Year 3 | Rs. 10 Lakhs | +30% | Rs. 13 Lakhs |
| Year 5 | Rs. 10 Lakhs | +50% | Rs. 15 Lakhs |
7. Restoration Benefit
If you exhaust your sum insured in one year, a restoration benefit replenishes coverage for the remainder of the year — especially valuable for family floater plans.
8. AYUSH Treatment Coverage
IRDAI mandates coverage for Ayurveda, Yoga, Unani, Siddha, and Homoeopathy (AYUSH) treatments. Check if there is a sub-limit for AYUSH hospitalisation.
9. Organ Donor Expenses
If you are the recipient of a transplant, a good plan covers the organ donor's hospitalisation and surgery costs as well.
10. Domiciliary Hospitalisation
If you cannot be moved to a hospital due to condition severity or unavailability of beds, some plans cover home-based medical treatment under professional supervision.
Value-Added Benefits Worth Having
11. OPD Cover
- Doctor consultations (general and specialist)
- Prescribed medicines and diagnostics without hospitalisation
- A premium add-on, but high value for families with young children or seniors
12. Maternity and Newborn Benefits
- Normal delivery and C-section hospitalisation expenses
- Pre- and post-natal consultations
- Newborn coverage from day one
- Waiting period typically 2–4 years — buy early
13. Mental Health Cover
Following the Mental Healthcare Act, 2017, IRDAI mandated coverage for mental illnesses on par with physical conditions — including hospitalisation for depression, anxiety disorders, and bipolar disorder.
Benefits by Plan Type
| Benefit | Basic Plan | Comprehensive Plan | Premium Plan |
|---|
| In-patient hospitalisation | Yes | Yes | Yes |
| Day-care procedures | Limited | 100+ | 100+ |
| Pre/post hospitalisation | 30/60 days | 60/90 days | 60/180 days |
| No Claim Bonus | 5–10% | 10–50% | 10–100% |
| Restoration benefit | No | Yes | Yes (unlimited) |
| OPD cover | No | Add-on | Included |
| Maternity cover | No | Add-on | Included |
Benefits People Frequently Forget to Use
- Annual health check-up: Most plans include one free check-up per year. Use it — it is already paid for.
- Teleconsultation: Many plans now include free or discounted virtual doctor consultations.
- Wellness benefits: Discounts on gym memberships, pharmacy, and diagnostics via insurer wellness programmes.
- No Claim Bonus strategy: Avoid making small claims that barely exceed your deductible — protect your NCB for larger claims.
Frequently Asked Questions
Does health insurance cover pre-existing diseases?
Yes, after the waiting period (typically 2–4 years). Once served, pre-existing conditions are covered like any other illness. This is why buying early matters so much.
Is outpatient treatment covered?
Standard plans do not include OPD. You need an OPD rider or a plan that includes it. With rising consultation costs in metro cities, OPD cover is increasingly worth considering.
Does health insurance cover mental health treatment?
Yes, following IRDAI's directive. Conditions like severe depression, schizophrenia, and bipolar disorder requiring hospitalisation should be covered. Check your specific policy terms.
Ready to Make a Smarter Health Decision?
Let a TatvaPlus expert help you find the right health insurance plan for your age, health profile, and budget — at absolutely no cost to you.
