Health insurance protects you and your family from big medical bills. It helps pay for hospital stays, surgeries, doctor fees, tests, and sometimes medicines. A good plan lowers out‑of‑pocket costs and gives financial peace of mind. This guide explains in simple words what health plans cover, what they usually exclude, how premiums are set, how to pick the right policy step by step, how to make claims, and a ready comparison table.
What a health policy usually covers
Most health plans pay for inpatient hospital costs: room and ICU charges, surgeon and doctor fees, tests done during the hospital stay, medicines and items used in hospital, and a set number of days for treatment before and after hospitalization. Many plans also cover day‑care procedures (like cataract surgery or dialysis) and offer cashless treatment at network hospitals where the insurer pays the hospital directly after approval.
What is usually excluded
Policies often do not cover pre‑existing conditions during a waiting period, cosmetic or elective procedures, self‑harm or injuries from illegal activity, and treatment related to drug or alcohol misuse. Experimental treatments and unapproved drugs are not covered. Maternity care, mental health, and some chronic illnesses may have separate waiting periods or limits. Always read the exclusions in the policy document to avoid surprises.
Main types of health plans
Individual plan: Covers one person. Good when someone in the family has health risks and needs their own limit.
Family floater: One pooled sum that covers all listed family members. Cost‑effective for young, low‑risk families.
Senior citizen plan: Designed for older people. Premiums are higher but coverage for age‑related conditions is better.
Top‑up / Super top‑up: Extra cover that starts after a chosen deductible is used up. It gives higher protection for big bills at lower regular cost.
Critical illness plan: Gives a lump‑sum payment if you are diagnosed with listed serious illnesses (like cancer or heart attack). It helps pay for long treatment and recovery.
Maternity / OPD riders: Optional add‑ons for childbirth and outpatient visits. These usually have long waiting periods.
How premiums are calculated
Insurers set premiums based on age, health, and medical history — older people and those with pre‑existing conditions pay more. Higher sum insured means higher premium. Location matters because hospital costs differ by city. Policy features like deductibles, co‑payments, and riders change the premium. Many insurers give discounts for claim‑free years or online purchases.
Step‑by‑step: How to choose the right health policy
- Make a needs list: Note ages of family members, chronic illnesses, planned pregnancies, and ongoing treatments.
- Decide sum insured: Check typical hospital costs in your city. For family floaters pick a limit that can cover a major hospitalization for one member and moderate costs for others. For individual plans pick limits based on each person’s age and health.
- Check waiting periods: Pre‑existing conditions and maternity often have 1–4 year waiting times — read the policy carefully.
- Check inclusions and limits: Look for per‑illness caps, room rent limits, and other sublimits that reduce real coverage.
- Verify network hospitals and cashless support: Make sure your preferred hospitals are in the insurer’s network for easier treatment.
- Check claim settlement ratio and reviews: Choose insurers with fast, fair claim handling and good customer feedback.
- Decide on riders and top‑ups: Add maternity, critical illness, or OPD only if needed. Consider a top‑up for large, rare expenses.
- Check portability and renewability: Portability lets you move to another insurer without restarting waiting periods. Prefer lifetime renewability for long‑term cover.
- Read the fine print: Understand definitions (pre‑existing condition, waiting period, co‑payment), renewal rules, and grievance process.
- Buy and organize documents: Save digital and paper copies of the policy, keep a claim checklist and emergency numbers, and set renewal reminders.
How to file a claim — simple steps
For cashless claims: inform the insurer or hospital, get pre‑authorization, and the hospital will request payment from the insurer.
For reimbursement claims: pay the hospital, collect original discharge summary, test reports, prescriptions, bills and receipts, fill the insurer’s claim form, and submit within the allowed time (usually 15–30 days). Keep scanned copies of everything. If a claim is rejected, ask for a written reason, check for missing documents or clauses, contact the insurer’s grievance cell, and if needed file with the insurance ombudsman.
Ways to lower premiums without losing core cover
Choose a higher deductible or a top‑up plan to reduce regular premium. Use a family floater for small, low‑risk families. Renew on time to keep no‑claim bonuses and portability benefits. Buy only needed riders. Maintain good health and give accurate medical history to avoid disputes later.
Family floater vs individual when to choose which
Choose family floater if your family is young and low risk and you want simple, cost‑effective cover. Choose individual plans if family members are older or have chronic illnesses — individual plans give separate limits and prevent one person’s claim from using up the whole family cover.
Short FAQ
Q: How much sum insured is enough for a family floater?
A: Base it on local hospital costs. Common starting ranges are $50,000–$100,000 depending on city and family size.
Q: Can I add maternity cover later?
A: Yes, but maternity riders usually have long waiting periods (often 2–4 years).
Q: What is portability?
A: Portability lets you move your current policy to a new insurer while keeping waiting‑period credits you have already served.
Comparison table
| Provider | Plan name | Type | Sum insured | Monthly premium | Key benefits | Waiting period |
|---|---|---|---|---|---|---|
| Insurer A | Family Care Plus | Family floater | $75,000 | $45 | Cashless network hospitals; maternity rider available | 24 months for pre‑existing |
| Insurer B | Health Secure Individual | Individual | $25,000 | $18 | No sublimits; OPD rider optional | 12 months for pre‑existing |
| Insurer C | Senior Health Protect | Senior plan | $50,000 | $60 | Chronic disease cover; higher ICU limits | 36 months for many pre‑existing |