Most health insurance buying mistakes happen not from choosing the wrong insurer but from not reading the specific clauses that govern claims. Brochures and comparison aggregator tables show headline features; the policy document shows what actually gets paid. This 10-point checklist targets the clauses that determine real claim payouts.
How to Use This Checklist
Before purchasing any health insurance plan:
- Download the policy document (Policy Wordings / Terms and Conditions) from the insurer’s official website
- For each checklist item, find the specific section in the policy document
- Note the exact clause, not the brochure summary
- Compare two or three plans using the same checklist
Checklist Point 1: Room Rent Sub-Limit
What to check: Does your policy limit daily hospital room rent? If yes, at what amount or percentage of SI?
Where to find it: Schedule of Benefits, row labelled “Room Rent” or “Room Category”
What it means: If you exceed the room rent limit, all other claim components (surgeon fees, ICU charges, medicines) are reduced proportionately. A ₹5,000/day limit in a ₹15,000/day room reduces a ₹5 lakh surgeon fee to ₹1.67 lakh.
Green flag: No sub-limit / Single Private AC Room with no rupee cap
Red flag: Specific rupee cap per day or percentage of SI cap
Checklist Point 2: Pre-Existing Disease (PED) Waiting Period
What to check: What is the waiting period before your declared conditions are covered?
Where to find it: Policy Terms, Section on “Waiting Periods” or “Exclusions”
What it means: Hospitalisations related to declared conditions are not covered during the waiting period (typically 3 years). Any non-declared condition that is later discovered counts as non-disclosure.
Green flag: 2-year or shorter PED wait; or portability from existing policy with waiting period credit
Red flag: 4-year PED wait; conditions permanently excluded (vs waiting period)
Checklist Point 3: Co-Payment
What to check: Is there any mandatory co-payment? Under what conditions?
Where to find it: Policy Terms, Section “Co-Payment” or “Patient Share”
What it means: Co-pay = you pay a fixed percentage of every approved claim. 20% co-pay on ₹5L claim = ₹1 lakh out of pocket, every time you claim.
Green flag: No mandatory co-pay
Red flag: 20%+ mandatory co-pay; age-triggered co-pay above 60
Checklist Point 4: Claim Settlement Ratio (CSR)
What to check: What is the insurer’s most recent CSR published in the IRDAI Annual Report?
Where to find it: IRDAI Annual Report (irdai.gov.in) — current year; or insurer website
What it means: Higher CSR = fewer claims rejected relative to total received. Compare same-year figures across insurer shortlist.
Green flag: Above 95% (standalone health insurers); above 88% (composite insurers)
Red flag: Below 85%; significant year-on-year deterioration
Checklist Point 5: Network Hospital List
What to check: Are your preferred hospitals (for routine care) in the insurer’s network?
Where to find it: Insurer’s website under “Network Hospitals” or “Cashless Hospitals” — usually a searchable list or downloadable PDF
What it means: Cashless treatment is only available at network hospitals. For non-network hospitals, you pay upfront and claim reimbursement — with possible co-pay.
Green flag: Your preferred hospital is in-network; large network (10,000+) with metro and Tier-2 presence
Red flag: Preferred hospital not in network; network primarily metro only for a Tier-2 city buyer
Checklist Point 6: Restore Benefit
What to check: Does the plan restore the SI after exhaustion? For same illness or different illness only?
Where to find it: Schedule of Benefits row “Restore Benefit” and policy definition section
What it means: Restore reinstates the SI after it is exhausted by a claim. Same-illness restore (Niva Bupa ReAssure 2.0) is more buyer-friendly than different-illness only (standard plans).
Green flag: Unlimited restoration; same-illness restore
Red flag: No restore; restore only for different illness; capped at one restoration per year
Checklist Point 7: Consumables Coverage
What to check: Are consumables (gloves, syringes, PPE, bandages) covered?
Where to find it: Policy Terms or the Schedule of Benefits; or explicitly in the Exclusions list
What it means: Consumables add ₹15,000–₹50,000 to a typical hospitalisation bill. Most standard plans exclude them. HDFC Ergo Optima Secure covers them.
Green flag: Consumables included in base plan
Red flag: Excluded (standard); add-on available at extra premium
Checklist Point 8: Procedure Sub-Limits
What to check: Are specific procedures (cataract, hernia, knee replacement) capped at amounts below the SI?
Where to find it: Schedule of Benefits — look for a table listing procedure-specific limits
What it means: A ₹10 lakh SI plan may cap cataract surgery at ₹25,000 per eye. The remaining ₹9.975 lakh is not available for cataract claims — only for other procedures.
Green flag: No procedure-specific sub-limits; or sub-limits comfortably above current treatment costs
Red flag: Low sub-limits on common procedures your family is likely to use
Checklist Point 9: Sum Insured Adequacy
What to check: Is the SI level sufficient for your city’s private hospital costs?
Benchmark guidance:
- Metro cities: Minimum ₹15 lakh for a family of 4
- Tier-2 cities: Minimum ₹10 lakh
- Supplement with a super top-up to extend protection cost-effectively
Checklist Point 10: Exclusions List
What to check: Read all exclusions — what does this plan NOT cover?
Where to find it: Policy Terms, Section “Exclusions” — typically Section 10
Key exclusions to note: Dental/vision, cosmetic procedures, self-inflicted conditions, substance abuse, specific hereditary conditions, non-allopathic treatments (unless Ayush add-on), experimental treatments.
What to do: If any exclusion overlaps with a known or likely need, evaluate whether the plan is appropriate.
Disclaimer: PolicyJack is an independent research platform. We do not sell insurance, receive commissions, or have commercial relationships with any insurer.