These terms directly affect how much money you get at claim time. Not knowing these is the most common reason people lose lakhs even when they have insurance. Read these before your next renewal.
Your policy says you can only spend ₹X per day on a hospital room. If you take a more expensive room, the insurer cuts EVERYTHING proportionately — not just the room bill.
| Expense | Actual Bill | Insurer Pays | You Pay |
|---|---|---|---|
| Room (5 days) | ₹30,000 | ₹15,000 | ₹15,000 |
| Surgeon fees | ₹80,000 | ₹40,000 | ₹40,000 |
| ICU charges | ₹50,000 | ₹25,000 | ₹25,000 |
| Medicines | ₹20,000 | ₹10,000 | ₹10,000 |
| Total | ₹1,80,000 | ₹90,000 | ₹90,000 |
A percentage of every claim you must pay from your own pocket, no matter what. The insurer pays the rest.
| Scenario | Total Bill | Insurer Pays | You Pay |
|---|---|---|---|
| 0% co-pay (good policy) | ₹2,00,000 | ₹2,00,000 | ₹0 |
| 20% co-pay (watch out) | ₹2,00,000 | ₹1,60,000 | ₹40,000 |
| 30% co-pay (senior policy) | ₹2,00,000 | ₹1,40,000 | ₹60,000 |
A period during which certain conditions or treatments are NOT covered, even though you are paying premium. There are two types — initial waiting period (usually 30 days) and pre-existing disease waiting period (1-4 years).
Any illness, condition, or injury you had before buying the policy. Insurers typically exclude these for 2-4 years from policy start date.
Cashless means the hospital bills the insurer directly — you pay nothing upfront. Reimbursement means you pay the hospital first, then submit bills to the insurer and wait for the money back.
The maximum amount your insurer will pay in a policy year. Once exhausted, you pay 100% of further medical bills yourself — until the next policy year begins.
Conditions, treatments, or situations your policy will NEVER cover, regardless of circumstances. This list is usually long and in small print.
Medical procedures that used to require overnight hospitalisation but now take less than 24 hours due to medical advances. Good policies cover these. Bad ones don't.
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These terms don't always affect claims directly but can make a significant difference at renewal time. Understanding these helps you negotiate better terms and avoid nasty surprises.
A reward for not making any claims in a year — your sum insured increases (or premium decreases) at renewal. Most policies give 5-50% bonus per claim-free year.
| Year | Effective Cover | Extra Cover Gained |
|---|---|---|
| Year 1 | ₹5,00,000 | — |
| Year 2 | ₹5,50,000 | +₹50,000 |
| Year 3 | ₹6,00,000 | +₹1,00,000 |
| Year 5 | ₹7,00,000 | +₹2,00,000 |
| Year 10 | ₹10,00,000 | +₹5,00,000 free |
If your sum insured is exhausted during the year, this benefit automatically tops it back up — either once or multiple times — so you're never left without cover.
| Without Restore | With Restore | |
|---|---|---|
| First claim (June) | ₹9,00,000 paid | ₹9,00,000 paid |
| Cover remaining | ₹1,00,000 left | ₹10,00,000 restored |
| Second claim (Sept) | ₹1,00,000 covered | ₹8,00,000 covered |
| You paid out of pocket | ₹7,00,000+ | ₹0 |
Caps on specific treatments or expenses within your overall sum insured. Even if you have ₹10 lakh cover, a sub-limit of ₹50,000 on cataract surgery means that's the max you'll get.
Your IRDAI-mandated right to switch your insurance policy from one company to another without losing the waiting period credit you have accumulated. You don't start from zero.
Coverage for medical expenses before admission (tests, consultations, medicines) and after discharge (follow-up visits, medicines) — not just the hospital stay itself.
Hospitals that have a direct billing agreement with your insurer, allowing cashless treatment. Non-network hospitals require you to pay upfront and claim reimbursement later.
Individual policy gives each person their own sum insured. Family floater gives one shared pool for the entire family — cheaper, but riskier if one member has a big claim.
The number of days after your renewal date during which you can still pay the premium without losing your policy and accumulated waiting period benefits.
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Our AI flags every gap, sub-limit, and missing benefit — in plain English
These terms are good background knowledge. They won't necessarily affect your next claim but understanding them makes you a smarter policyholder when talking to your broker or insurer.
Coverage for doctor consultations, diagnostic tests, and medicines without hospitalisation. Most standard policies don't include this — it's usually an add-on.
Coverage for Ayurveda, Yoga, Unani, Siddha, and Homeopathy treatments in recognised hospitals. IRDAI now mandates that insurers offer this — but limits vary widely.
Coverage for treatment taken at home when the patient cannot be moved to a hospital or the hospital doesn't have beds. Usually covered for 3+ days of continuous treatment.
A separate benefit that pays you a lump sum if you're diagnosed with a specified serious illness — cancer, heart attack, stroke, kidney failure etc. — regardless of actual treatment cost.
Coverage for normal delivery, caesarean section, and newborn care. Almost always comes with a waiting period of 2-4 years and a fixed sub-limit.
Covers the cost of air ambulance evacuation in medical emergencies where ground transport is not possible or safe. Usually capped at ₹2.5-5 lakh.
Insurance Regulatory and Development Authority of India. The government body that regulates all insurance companies, sets minimum coverage standards, and handles policyholder grievances.
Insured Declared Value — the current market value of your vehicle. This is the maximum amount you'll receive if your car is stolen or completely destroyed. It decreases every year as your car depreciates.
An add-on for car insurance that ensures the insurer pays the full cost of replacing parts without deducting depreciation. Standard car insurance deducts 40-50% for older parts.
| Part Replaced | Actual Cost | Without Zero Dep | With Zero Dep |
|---|---|---|---|
| Bumper | ₹20,000 | ₹10,000 | ₹20,000 |
| Headlights | ₹15,000 | ₹7,500 | ₹15,000 |
| Bonnet | ₹25,000 | ₹12,500 | ₹25,000 |
| You pay | ₹60,000 | ₹30,000 | ₹0 |
A 15-30 day window after buying a new policy during which you can cancel it for a full refund if you're not satisfied, no questions asked. IRDAI mandates this for all policies.
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See exactly which of these terms your policy has, which are missing, and what to fix