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Health Insurance Policies - Fine Prints

Written by Dr. Sameer Sippy | Medically Reviewed by The Medindia Medical Review Team  on Nov 23, 2016
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Health insurance is one definite way towards achieving ‘health for all’ in the world. Most governments including the US government are striving towards this goal. UK already has the National Health Service and so have most European countries. But it is the lesser developed countries that need to get health insurance high on the government’s priorities and demand a higher chunk of the GDP.

Health Insurance Policies

In India, health insurance is gathering momentum, with many state governments tying up with private insurance companies to provide decent health cover for their people. Healthcare in India is seeing a gradual shift of focus from public sector hospitals to private corporate hospitals. However, by and large the common man is still ignorant about the very concepts of Insurance. Health Insurance is only a component of different types of insurance cover.During the last elections - ‘Health insurance for people’ became a new mantra for capturing vote-banks in some states of India. It is very well for the government to give pledges to the people to win votes, but the challenge to deliver decent health-care to their subjects in the comfort of the corporate hospitals is likely to be daunting. The premium paid is sometimes very meager and can provide for very little.


Understanding the fine print of the insurance will help you understand the scope of the policy and its limitations, which are seldom spelled out by the agent selling you their products. This article has been created specially for the layman, to explain, discuss and interpret only the important clauses incorporated under Health Insurance Policy by various PSUs (Public Sector Undertakings) and Private Insurance Companies in India.

Before discussing and interpreting the important clauses as stated in the policy cover, it is important to note that there are no standard inclusions or exclusions, and the numbers and wordings of the clauses varies from organization to organization (both – PSUs and private insurance companies), however the contents i.e. Terms and Conditions remain more or less uniform based on the guidelines issued by IRDA (Insurance Regulatory and Development Authority) - a regulatory body for the Insurance sector in India which is a subject under Central Government of India.


Broadly the Insurance sector is divided into Life insurance and General Insurance sector as depicted in the following table -

Classification of Indian Insurance Sector

Health Insurance-Classification

As depicted in the classification chart, health insurance is one of the constituents of Non-Life/General Insurance sector in India.

  1. Best Health Insurance Policy in India - (https://www.apnapaisa.com/insurance/health-insurance-india/index.html)
Disclaimer: The contents of the article are in tune with the regulations in Insurance and TPAs (Third Party Administrators) since the past 2 years. The same rules are likely to prevail and be in force for the year 2009-10, unless changes/modifications/alterations/deletions/additions in existing regulations are made by the Insurance Companies, in tune with the guidelines issued by IRDA (Insurance Regulatory Development Authority). The author of this article does not take responsibility for changes made in the existing health insurance policy coverage which would occur with passage of time.

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Hi, My father [Age-62yr] underwent Cardiac by-pass surgery in 2006 and after that he undergoes annual cardiac check-up every year. He is in good health now. I want to take a Mediclaim policy for him which covers him for any possible future hospitalization (for all generally covered diseases including his pre-existing condition). Please recommend me good options which is also not very expensive.


Hi, I reside in a Metro city and my child is admitted in a Child Care Centre / Nursing Home last night due to illness last night. However the Nursing Home is a small one and has 5-6 beds only. But it is registered one under the regulatory authorities. I seek clarification on below: "HOSPITAL/NURSING HOME: means any institution in India established for indoor care and treatment of sickness and injuries and which either Is duly licensed and registered as a Hospital or Nursing Home with the appropriate authorities and is under the supervision of a registered and qualified Medical Practitioner. OR In areas where licensing and registration facilities with appropriate authorities are not available, the institution must be one recognised in locality as Hospital / Nursing Home andshould comply with minimum criteria as under: [1] It should have at least 15 in-patient medical beds in case of Metro cities, A Class cities......................." Will I be able to claim for reimbursement? Regards, Sameer


My Wife was Pregnant and was in 9th month. All was normal but one night we finish our dinner and went to our bed. But suddenly at midnight my wife found Heavy Bleeding. We immediately run for our Doctor treating her. She refer us to one of the Big n Best Hospital of our city. The problem raised is called Ante partrue Hemarhage [APH] according to Doctor. As due to heavy bleeding my wife was almost in shock. And to save the life of both (Baby n Mother) a Emergency LSCS was done. A baby born via Cesarean. So, I submit a file for claim against my Medical Policy with United India Insurance Co. but that was rejected by saying "Treatment arising from or traceable to Pregnancy (including Caesarean) not covored. But as per me, as My Wife have no Labour Pain nor the whole process was done because of or for Delivery. So, kindly guide me for the same. Should I go to Insurance Ombudsman???


I am 26 years old and I would like to undergo Lasik Operation. My sight is -7 in both eyes. Can I get free operation in Hospitals?

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