Insurance policy documents make for a cumbersome read. But if you don’t want to be caught unawares later, it’s important to read a policy document before you sign up. Look for details on which expenses are covered and which ones aren’t, the terms and conditions that limit how you can utilise certain benefits, and whether your overall cover (the sum insured) can be enhanced by features such as restoration benefit, and the like.

Here, we highlight five things to look at in a health insurance policy document. This list is not exhaustive but highlights a few important things that can vary from one policy to another.

Waiting period

A health insurance policy has three types of waiting periods—a standard 30-day waiting period, a pre-existing diseases / ailments (PED) waiting period, and a specified disease/procedure waiting period. That is, the insurance policy provides coverage only after the elapse of these waiting periods, wherever relevant.

Under the standard waiting period, expenses related to the treatment of any illness within 30 days from the issuance of your first policy are not covered. This is a standard in all policies. The only exception is claims resulting from an accident.

Under the PED waiting period condition, coverage for any pre-existing disease starts only after a waiting period of two to four years from the date of issuance of the first policy. A PED is defined as any illness or condition that was diagnosed, or for which medical advice or treatment was recommended or received from a physician up to 48 months prior to the policy being issued.

Let’s look at this with an example. Suppose you were diagnosed with diabetes in March 2018 and you apply for and are issued a health insurance policy in January 2021. Then, your diabetes, which was diagnosed less than 48 months before, will qualify as a PED. If the policy has a PED waiting period of say three years, then you will start being covered for diabetes only after January 2024, once the three-year waiting period is over.

Different policies can have different waiting periods for PEDs. For example, Manipal Cigna Health Insurance Company’s ProHealth Prime Advantage plan covers PEDs only after 24 months of continuous coverage where the sum insured is Rs 7.5 lakh or higher. For policies with a sum insured of up to Rs 5 lakh, the insurer has a waiting period of 36 months. Bajaj Allianz General Insurance Company’s Extra Care plan provides cover for PEDs only after a 48-month waiting period. But the company’s Extra Care Plus plan has a shorter PED waiting period of only 12 months.

And finally, insurance policies also have a waiting period for a set of specified diseases/procedures (relating to specific gynaecological, orthopaedic, gastrointestinal issues etc) as listed in the policy document. These usually have a waiting period of two years, though that could be shorter in some cases.

Also read: Moneycontrol-SecureNow Health Insurance Ratings: Your guide to picking the right health policy

Room rent capping

If you get hospitalised, your insurer may not always fully cover the expense on account of room rent. That is, even though your hospitalisation bill is well within your sum insured, your insurer may cover your room rent only up to a certain extent. Alternatively, some insurers may specify the type of room that you are eligible for under your policy. In both cases, if you exceed the room rent cap or opt for a room type that is better than what you are entitled to, you will have to bear the extra cost. Your policy document will mention these details.

Under the Manipal Cigna ProHealth Prime Active plan, if your sum insured is Rs 3 lakh, your room rent gets capped at 1 percent of this amount. Those with a sum insured of Rs 5 lakh or higher, are eligible for a single, private air-conditioned room. In the case of admission to the ICU, however, your room rent is taken care of as long as it is within your sum insured. Niva Bupa’s Health Premia (platinum plan), covers your room rent to the extent of the sum insured in all cases.

HDFC Ergo General Insurance Company covers room rent based on actuals (actual expense incurred) under policies such as Optima Suraksha, Optima Secure and Optima Super Secure.

Pre and post hospitalisation period

A health insurance policy covers not only your hospitalisation expenses (on consultations, investigations and medicines) but also related expenses incurred up to a few days before and after the hospitalisation. This applies not only in the case of in-patient treatment (actual admission in a hospital) but also for domiciliary treatment (which normally requires hospitalisation but is undertaken at home due to reasons such as the patient’s condition etc.). There can be variations in this across insurance policies.

For example, HDFC ERGO Optima Restore plan covers expenses up to 60 days before the date of hospitalisation and up to 180 days after discharge from the hospital in case of both in-patient treatment and domiciliary treatment. On the other hand, the Manipal Cigna ProHealth Prime Protect plan covers expenses up to 60 days before the date of hospitalisation and up to 180 days after discharge from the hospital only in case of in-patient treatment. For domiciliary treatment, cover is only for up to 30 days before the date of hospitalisation and up to 30 days after discharge.

Also hear: Simply Save | Your guide to picking the right health insurance policy

Restoration / re-loading of sum insured 

Check if your health insurance policy provides restoration / re-loading benefit, something that not all policies do. This is a useful feature that helps restore your insurance cover to the original sum insured once it is used up. It can provide you and your family adequate health cover in a year where you have had to file multiple claims. But this benefit can come attached with many terms and conditions.

For example, many policies may not allow you to use the restored sum insured for claims towards the same illness / injury to the same person for which a claim has already been paid in the same year. That’s how this benefit works under, say, the Manipal Cigna ProHealth Select plan and the Royal Sundaram Family Plus plan. For instance, if Mr A has already filed a claim for ailment XYZ, then he cannot use the restored sum insured for another claim relating to XYZ in the same year. But, he can file another claim relating to some other ailment. Or, in case of a family floater policy, Mr A’s spouse can file a claim relating to the XYZ ailment. A few policies such as HDFC ERGO Optima Secure, however, do not have such restrictions on the restored sum insured.

Under all policies, the restoration benefit triggers only from the second claim onwards. So, if your first claim for a year is for Rs 6 lakh and your base SI is Rs 5 lakh, then Rs 1 lakh will have to be borne by you. Also, any unutilised restored SI cannot be carried forward to the next year.

Health check-ups 

Many insurance policies allow you the benefit of a complimentary health check-up, usually, once a year. But there can be variations in this. Read the policy document to know exactly what is being offered. For example, under the Niva Bupa Health Premia Policy (silver and gold plan), depending on the sum insured, you become eligible for annual tests worth Rs 1,250 to Rs 7,500 per insured person.

In the case of the ManipalCigna ProHealth Protect and Accumulate plans, a health check-up is available only once every third policy year, whereas under the ProHealth Plus, Preferred and Premier plans, it is available each policy year excluding the first year. Furthermore, depending on the plan and the sum insured, you become eligible for a certain specified list of tests.

If you want to read the exact wording of any health insurance policy, you can download the policy document from the website of the insurer. It can be found either where the policy description has been provided or in the downloads section of the website.