Most people check the premium, click buy, and move on. Then they discover — during a hospitalisation — that their plan does not cover what they assumed it did. A few extra minutes now can save you lakhs later.
The 15-Point Health Insurance Checklist
1
Sum Insured — Is It Adequate?
Metro cities: Minimum Rs. 10 lakhs per person. Tier 2 cities: Rs. 5–7 lakhs. Family of 3–4: Rs. 20–25 lakh floater recommended. Avoid Rs. 2–3 lakh coverage — it is almost never enough today.
2
Waiting Periods
Initial/General: 30 days. Pre-existing disease: 2–4 years. Specific illness: 1–2 years. Maternity: 2–4 years. Understand waiting periods before hospitalisation.
3
Room Rent Limit
A room rent cap can reduce all related charges proportionally — not just room cost. Look for plans with no cap or at least a single-room limit.
4
Network Hospital Coverage
Does the insurer have a large network in your city? Are your preferred hospitals in the network? Are hospitals conveniently located near home and workplace?
5
Claim Settlement Ratio (CSR)
97–100%: Excellent (Preferred). 94–97%: Good (Acceptable). 90–94%: Average (Review carefully). Below 90%: Poor (Consider alternatives).
6
Pre and Post-Hospitalisation Cover
Pre-hospitalisation: 30, 60, or 90 days? Post-hospitalisation: 60, 90, or 180 days? Are follow-ups, medicines, and diagnostics included?
7
Day-Care Procedures
Plan should cover 100+ day-care procedures including cataract, dialysis, chemotherapy, angioplasty. Avoid plans that require minimum 24-hour stay for all treatments.
8
Restoration Benefit
Does the insurer restore 100% of sum insured after exhaustion? Especially important for family floater plans. Restoration for same illness is rarer — check terms carefully.
9
Co-Payment Clause
Younger buyers: prefer plans with zero co-payment. Co-pay plans have lower premiums but higher out-of-pocket costs during claims.
10
Sub-Limits on Specific Treatments
Check for capping on ICU charges, specific surgeries, OPD. Modern comprehensive plans are moving away from sub-limits.
11
AYUSH Coverage
Is AYUSH hospitalisation (Ayurveda, Yoga, Unani, Siddha, Homeopathy) covered? What is the sub-limit, if any?
12
Maternity and Newborn Cover
Is maternity (normal and C-section) covered? Is the newborn automatically covered from day one? What is the waiting period and sub-limit?
13
Critical Illness Add-On
Is a critical illness rider available? Consider a standalone critical illness plan for larger lump-sum protection.
14
Policy Portability Rights
Can you switch insurers with waiting period credits retained? Does the insurer support smooth portability?
15
Premium History and Renewability
Check 3-year premium escalation history for the insurer. Lifetime renewability must be guaranteed (IRDAI requirement). Confirm no age-based exclusions at renewal.
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Frequently Asked Questions
What is the most important thing to check in a health insurance plan?
The Claim Settlement Ratio and exclusion list are the most critical. A cheap plan that rejects claims is worthless. Always check the IRDAI-published CSR and read every exclusion carefully.
Is a family floater better than individual plans?
A floater is cost-effective when all members are young and healthy. If one member is older or frequently hospitalised, they could exhaust the shared sum insured. Consider individual plans for older parents.
Should I choose a plan with no room rent capping even if it costs more?
Yes, in most cases. A room rent cap reduces all related claim components proportionally — not just room cost. The slightly higher premium for a no-cap plan is usually worth it in metro cities.
