Health insurance
Everything that decides whether your health claim is paid
A reference page rather than a pitch. It covers how much cover families in different cities commonly hold, the six clauses that decide a claim, and the published claim record of every health insurer we can place business with.
- Structure
- Floater or individual
- Payment
- Cashless network
- Conditions
- Waiting periods apply
- Oversight
- IRDAI-regulated
How much cover do you actually need?
Enough to cover the most expensive week your family is realistically likely to have, in the city where they would be treated. In a metro, a cardiac bypass or a serious accident admission commonly runs from ₹4 lakh to ₹12 lakh, an oncology course can pass ₹15 lakh across a year, and hospital tariffs have been rising faster than general inflation. In a tier 3 town the same procedures cost roughly half.
Set your profile
Range commonly considered
This is the range families with this profile commonly consider, drawn from what our own clients hold and from published hospital tariffs. It is not a figure calculated for you, and your medical history, existing employer cover and budget all move it. A top-up sitting above a smaller base policy often reaches the same ceiling for less.
What actually decides whether your claim is paid?
Six clauses, all of them in the policy wording rather than the brochure. A claim is rarely refused outright. More often it is paid in part, and these are the six reasons why.
| Term | What it is | What to watch for |
|---|---|---|
| Room rent capping | A ceiling on the daily room charge the insurer will pay, often 1 percent or 2 percent of sum insured per day. | Take a room above the cap and the insurer scales down the whole bill proportionately, surgeon fees included. Prefer wording with no capping, or with a named room category. |
| Sub-limits | A rupee cap on specific procedures such as cataract, knee replacement or maternity, separate from your sum insured. | A ₹40,000 cataract sub-limit inside a ₹10 lakh policy is still a ₹40,000 payout. Read the annexure, not the headline number. |
| Co-payment | A fixed share of every claim you pay yourself, commonly 10 percent or 20 percent. | Often mandatory on policies bought after 60, or optional in exchange for a lower premium. On a ₹8 lakh claim, 20 percent is ₹1.6 lakh out of your pocket. |
| Pre-existing waiting period | The period before conditions you already had at purchase become payable, now capped by IRDAI at 36 months. | The clock starts at your first policy, so buying earlier is the only way to shorten it. Disclose every condition on the proposal form. Non-disclosure is the single most common reason a claim fails. |
| Disease-specific waiting | A separate wait, usually 24 months, on listed conditions such as hernia, cataract, piles or fibroids, whether or not you have them today. | This list differs between insurers more than any other clause. If a planned procedure is on it, the wait applies even when you were healthy at purchase. |
| Restoration | Refills the sum insured after it is exhausted during a policy year. | Check whether it triggers on partial or only full exhaustion, whether it covers the same illness, and how many times per year. On a floater it matters most, since one member can consume the whole cover. |
What a room rent cap does to a ₹5 lakh bill
Illustration, arithmetic onlyYour cap is ₹5,000 a day and you took a room above it, so the insurer applies 56% to the entire bill, not just the room line. Surgeon, theatre and investigation charges are all scaled down by the same fraction.
When each wait actually ends
Four different clocks run from the day your first policy starts, and most people read them as one date.
- Day 1
Accidents are covered
An accidental injury requiring admission is payable from the day the policy starts.
- 30 days
The initial wait ends
Illness claims begin. Nothing but accidents is payable in the first month.
- 24 months
Listed conditions begin
Disease-specific waits clear: hernia, cataract, piles, fibroids and the rest of the insurer's list.
- 36 months
Pre-existing conditions clear
The IRDAI cap. Anything you declared at purchase is now payable, and the clock ran from your first policy.
The clock starts at your first policy and carries over when you port, which is why buying earlier shortens it and buying cheaper does not. Individual products may run shorter waits; the policy wording governs.
Floater or individual?
A floater shares one sum insured across the family and is cheaper while everyone is young and healthy. Individual policies give each person their own cover and price on their own age. The pivot is usually the oldest member, because a floater is priced on them.
- Two adults under 45 with children, one premium, one renewal date
- Parents over 60, or any member with a condition that would price the whole floater up
- One serious claim can consume the cover for everyone that year
- Each person keeps their own sum insured regardless of the others
- Cheaper for the same headline cover
- Costlier, and simpler at claim time
Do I need a top-up?
A top-up pays only above a threshold, the deductible, which your base policy or employer cover is expected to absorb. Because it never pays the small claims, it costs a fraction of a full policy for the same ceiling. A super top-up applies the deductible across the year rather than per claim, which is what most families want.
- Worth it when
- You hold ₹5 lakh to ₹10 lakh of base or employer cover and want to reach ₹25 lakh or more without trebling the premium
- Not worth it when
- You have no base policy at all. A top-up with nothing underneath leaves the deductible payable by you on every admission
- Check
- Whether the top-up runs its own waiting periods, which it usually does, and whether it accepts your employer cover as the deductible
The six health insurers, side by side
Listed alphabetically, with no ranking and no verdict. A settlement ratio counts the share of claims settled, so it says nothing about how much of each bill was paid. Read it alongside the clauses above rather than on its own.
| Insurer | Settled, FY24-25 | Settled, FY25-26 | Network hospitals |
|---|---|---|---|
| Aditya Birla Health | 95.88% | Not published | 12,631 |
| Care Health | 96.74% | 96.99% | 11,506 |
| HDFC ERGO | 97.45% | 98.19% | 9,751 |
| ICICI Lombard | 83.65% | 91.96% | 10,378 |
| ManipalCignaHas not published a quarterly public disclosure since December 2022, so no current figure can be computed. | Not published | Not published | 7,193 |
| Niva Bupa | 92.39% | 94.44% | 10,413 |
The health insurers we can place6
Settlement ratio, financial years ending 31 March 2025 and 31 March 2026. Computed by Zenith from Form NL-37, the claims data each insurer files as a public disclosure under IRDAI rules: claims settled divided by claims settled plus claims repudiated, counted by number of claims across the insurer's whole health book. No regulator publishes this ratio for health insurers, so anyone quoting one has calculated it, and the basis they used changes the answer by several points.
Network hospitals, as on 31 March 2025. Network counts are the hospitals each insurer has a direct agreement with, as recorded by IRDAI for FY2024-25. Insurers advertise larger figures, often double, by counting clinics and diagnostic centres and hospitals reached through third-party administrators. The number that matters is not the total but whether the two hospitals you would actually use are on it.
How does Zenith get paid?
By the insurer, as commission built into the premium the insurer files with IRDAI. Nothing is charged to you, there is no fee for the conversation, and your premium is identical to buying direct from the insurer.
Health business is placed through our partner Motilal Oswal Financial Services Ltd. Commission rates differ between insurers, which is exactly why the choice is made on wording and claims record, and the rate is disclosed to you when you ask.
Health insurance questions, answered
Not if you declared it. Diabetes is a pre-existing condition, so claims arising from it wait out the pre-existing period, up to 36 months, while everything unrelated is covered from day one. Claims are refused for non-disclosure, not for the condition itself.
Usually not on its own. Group cover is commonly ₹3 lakh to ₹5 lakh with room rent caps and co-payments, it can be trimmed by your employer at renewal, and it ends with the job. Treat it as the first layer and hold a personal policy underneath it.
A cap on what the insurer pays per day for your hospital room. Exceed it and the insurer applies proportionate deduction, scaling down the entire bill including surgeon and theatre charges in the same ratio, not just the room line. It is the most expensive clause people ignore.
IRDAI caps the pre-existing waiting period at 36 months, and several insurers offer shorter waits of 24 or 12 months on specific products. The clock runs from your first policy start date and carries over when you port, which is why an early purchase is worth more than a cheap one.
Cashless means the insurer settles directly with a hospital in its network, after pre-authorisation. Outside the network you pay and file for reimbursement. Check that the two hospitals you would actually use are in the network before you buy, not the total count.
You can, but a floater is priced on the oldest member, so adding a 62 year old parent raises the premium for everybody. A separate senior policy for parents, with its own sum insured, is usually both cheaper and cleaner at claim time.
Only on policies that include a maternity benefit, and then after a waiting period of two to four years with a rupee sub-limit that rarely covers a metro delivery in full. If a pregnancy is two years away, the decision has to be made now.
There is a grace period, usually 30 days, in which you can pay and keep your accrued waiting periods. Nothing that happens during the gap is covered. Past the grace period the policy lapses and you start again as a new customer, waiting periods and all.
Yes, through portability. Apply 30 to 45 days before your renewal date and the credit you have accrued for waiting periods moves with you, on the sum insured you already held. The new insurer still underwrites you and can decline or load the premium.
Less than you would think. It counts the share of claims settled, not how much of each bill was paid, so an insurer that pays every claim in part scores the same as one that pays them in full. No regulator publishes it for health insurers, so every figure you see has been computed by someone. Read it alongside the room rent, sub-limit and co-payment clauses rather than on its own.
Next step
Read your wording with someone
Thirty minutes, on a call, going through the clauses above against the policy you hold or the one you are considering. If your cover is already right, we will tell you that.