Six clauses that decide whether a health claim is paid

A health policy is sold on its sum insured and settled on its wording. The gap between the two is where almost every unhappy claim lives, and it is nearly always one of six clauses.

All six are in the document you already have. They are worth finding on a quiet afternoon rather than from a hospital corridor.

1. Waiting periods

Nearly every policy has an initial window, usually thirty days, in which nothing but accidental injury is covered. Specific conditions such as hernia, cataract and joint replacement carry their own waiting periods, commonly two to four years.

This is why switching insurers casually is expensive. A new policy usually restarts these clocks unless the waiting periods are carried over through portability, which has to be applied for before the old policy lapses.

2. Pre-existing disease

Anything diagnosed before the policy started is treated separately and typically waits three to four years before it is covered. The definition is broader than most people expect, and it turns on what was diagnosed rather than what was treated.

The single most consequential thing you can do here is disclose everything at the proposal stage, including conditions that feel minor or historical. A non-disclosure found at claim time can void the policy entirely, which is a far worse outcome than a loading on the premium.

3. Room rent limits, and the deduction nobody expects

Some policies cap the room category or the daily room charge. The cap itself is not the problem. The problem is proportionate deduction: if you take a room costing twice your eligible limit, many policies reduce every associated charge in the same proportion, including the surgeon's fee and the operating theatre.

A bill of five lakh can settle at half that, on a clause about the room. If your policy has a room limit, know it before admission, because the choice is made at the admission desk.

4. Sub-limits

Individual procedures can carry their own ceilings regardless of your sum insured. Cataract surgery is the common example, frequently capped well below actual cost per eye.

A ten lakh policy with sub-limits is not a ten lakh policy for those procedures. The sum insured is the maximum, not the amount available for any given treatment.

5. Co-payment

A co-pay is a fixed share of every admissible claim that you bear yourself, often ten or twenty percent. It is common on policies bought at older ages and on some corporate plans.

It reduces the premium and it applies every single time. On a large claim it is a large number, so it is worth knowing whether yours has one before you need it rather than after.

6. Permanent exclusions

Some things are never covered, whatever the waiting period. The list varies by insurer and typically includes cosmetic treatment, most dental work unless caused by accident, and treatment arising from certain declared activities.

Since 2020 the regulator has standardised much of this language across insurers, which makes the exclusions section far easier to compare than it used to be. It is a short section and worth reading in full.

Where to find all six

Every one of these is in the policy wording rather than the brochure, and in most documents they sit within a few pages of each other under definitions, exclusions and the schedule of benefits.

If you would rather read yours with somebody who has read a few hundred of them, that is a conversation we are happy to have, and it does not require you to be a client.