How to read your health insurance policy
Your health insurance policy is a legal contract — and most people have never read it. Here's what to look for and where to find it.
The Policy Schedule vs. the Policy Wording
Your policy comes in two parts: Policy Schedule: A 2–4 page summary with your name, sum insured, premium, and key dates. This is what most people read. Policy Wording: The full legal document (often 30–60 pages) with all the actual terms, conditions, exclusions, and definitions. This is what matters when a claim is made. Always read the Policy Wording before buying, and keep it with your policy schedule.
The sections that matter most
1. Definitions: How your insurer defines "Pre-existing Disease", "Hospitalisation", "Day Care Treatment". These definitions determine whether your claim is valid. 2. Inclusions / What is Covered: Hospitalisation, pre and post, day-care, ambulance, etc. 3. Exclusions / What is NOT Covered: Permanent exclusions (cosmetic surgery, self-harm) and temporary exclusions (waiting period items). 4. Waiting Periods: Usually in its own section or a table. Note every type and duration. 5. Sub-limits: Caps on specific items — room rent, ICU, cataract, maternity. These can dramatically reduce your actual reimbursement. 6. Co-payment: The percentage of each claim you pay yourself. 7. Claim Procedure: How to file a cashless or reimbursement claim, and the intimation timeline.
The 5 questions to ask about any policy
1. What is the room rent sub-limit? A room rent cap of ₹5,000/day means ALL associated charges (doctor, nursing, investigations) are proportionately reduced if you stay in a costlier room. 2. What conditions are excluded? Look for permanent exclusions and scheduled exclusions. 3. How long are the waiting periods? Initial, PED, and specific disease waiting periods. 4. Is there a co-payment? Even 10% co-payment on a ₹5 lakh claim is ₹50,000 out of pocket. 5. What is the no-claim bonus? Some policies increase sum insured for claim-free years; others reduce premiums.
Red flags to watch for
- Proportionate deduction clause: Often buried in the room rent section. If you take a room above the sub-limit, all room-related charges are reduced proportionally. - Disease-specific sub-limits: Separate limits for cataract, joint replacement, etc. that are much lower than your total sum insured. - High PED waiting period: 4-year PED waiting periods are common but some policies offer 2 or even 1 year. Compare before buying. - Network hospital restrictions: Some policies only provide cashless at specific hospitals. Check if your preferred hospital is in the network.
Get a plain-English breakdown of your policy
Upload your policy PDF. We extract every exclusion, waiting period, sub-limit, and co-payment — and explain it in plain English.
Decode My Policy — ₹99