This article first appeared in Kannada in Arogyavani, the health supplement of the Udayavani daily, on 20 July 2025. ಈ ಲೇಖನವನ್ನು ಕನ್ನಡದಲ್ಲಿ ಓದಿ
Good health, they say, is the greatest wealth. But an unexpected illness, an accident or a surgery brings more than physical pain and mental stress; it also lands a large hospital bill on our shoulders. Health insurance is the practical way to protect ourselves and our families from such financial shocks. Yet even today, many people hesitate to buy a policy, and many more are confused about how it works.
This article explains, in simple terms, why health insurance matters, what you should know before you buy a policy, and how to use it wisely.
Why Does Health Insurance Matter?
Think of health insurance as the airbags in a car, or the parachute under an aeroplane seat. We hope we never have to use them. But when an accident does happen, what a relief it is that they were there!
In the same way, you may stay healthy for years without ever stepping into a hospital. The premium you paid all that while is not money wasted; it is an investment in your peace of mind and in the health security of your family.
If you never have to make a claim, that is, in truth, a blessing.
Without Insurance
Without insurance, one sudden illness can wipe out a lifetime of savings, force you to sell property, or push you into debt. With insurance, you can put the worry about the hospital bill aside and focus on getting better.
It is also important to review your policy every few years. As your age, the size of your family and your income change, the policy needs to be upgraded too: by adding add-ons, raising the cover, or moving to a more comprehensive plan.
Do Not Rely Only on Your Employer’s Insurance
Many working people have group insurance provided by their employer. It is useful, but usually not enough. It ends when you retire or change jobs. It may not cover your parents, and it may have limits on certain treatments.
So it is wise to buy an individual or family policy of your own: one that you control, and can continue for life.
Top-Up Policies
Also consider top-up policies. They give you a large additional cover for a small premium. A top-up comes into play only when the hospital bill crosses the limit of your base policy, and it protects you from very large medical expenses.
You Can Switch Insurers (Porting)
If you are unhappy with your present policy, you can move it to another company, just as you can port your mobile number to another service provider. You must apply at least 45 days before your policy is due for renewal. Porting carries your waiting periods and other benefits over to the new insurer.
Key Terms You Must Understand
Before you buy a policy, make sure you know these basics.
1. Pre-Existing Conditions
When you buy a policy, declare every existing illness honestly, whether diabetes, high blood pressure, asthma or anything else. If you hide one, a claim may be rejected later. Pre-existing conditions usually carry a waiting period of two to four years.
What Happened to One of My Patients
Not long ago, a patient of mine was admitted in a serious condition. They had a health insurance policy with good cover. But when buying it, they had not told the company about their asthma. An agent had advised them that declaring asthma would raise the premium, and that leaving it out would get the policy through easily.
Unfortunately, when the bill was claimed, the insurer went through the patient’s old medical records, found the undisclosed asthma, and rejected the entire claim. They had paid the premium faithfully for years, and still the patient and family were left in financial distress.
Whatever anyone else tells you, never hide a pre-existing illness.
They say you should never lie to your doctor or your lawyer. Now add a third to that list: your health insurance company.
2. Cover and Limits
The sum insured is the most your policy will pay in a year. For a family of four living in a city, a cover of at least ₹10 lakh is advisable. Look out for sub-limits, that is, caps on room rent or on particular treatments. As far as possible, choose a policy without them.
3. Room Rent Eligibility
Your policy may cover only a general ward or a shared room. If you take a private room without checking what you are eligible for, you will have to pay the difference in the bill yourself.
4. Expenses Before and After Admission
Good policies cover tests, scans, doctors’ visits and medicines for 30 days before admission and up to 90 days after discharge.
5. Day Care Procedures
Thanks to advances in modern medicine, procedures such as cataract surgery, chemotherapy and dialysis no longer need a 24-hour stay in hospital. Your policy should cover such day care procedures as well.
6. OPD and Inpatient Costs
Most basic policies pay only inpatient costs: the hospital stay, surgery and ICU bills. Outpatient (OPD) costs such as consultations, dental treatment and tests are not covered unless you add a special add-on.
7. Consumables
Hospitals charge for items such as gloves and syringes, and some policies do not cover them. Check whether your policy pays for such non-medical expenses, or offers an add-on for them.
8. The Claim Process and Pre-Authorisation
- For a cashless claim, you must choose a hospital in your insurer’s network.
- For a planned admission, inform the insurer 3 to 5 days in advance.
- In an emergency, inform them within 24 hours of admission. If you tell the hospital about your insurance at the time of admission, it usually takes care of this for you.
- If you are admitted to a hospital outside the network, you can pay the bill first and claim reimbursement from the insurer later.
Remember, being in a network hospital does not by itself guarantee cashless treatment. Approval depends on whether the treatment is covered by the policy, and whether admission is medically necessary.
9. Claim Settlement Ratio (CSR)
This is the percentage of claims an insurer approves. Choose a company with a CSR above 90%. The Insurance Regulatory and Development Authority of India (IRDAI) publishes these figures every year.
Special Situations
- 1. Pregnancy and newborn care: Maternity cover is available as an add-on, but it comes with a waiting period of 2 to 4 years. If maternity cover is active, some policies also cover the newborn from the first day.
- 2. Children: Children can be included in a family floater plan. Some policies also pay for vaccinations and annual health check-ups.
- 3. Senior citizens: If your parents are over 60, they will usually need a separate senior citizens’ policy. The premiums are higher, and there may be a co-payment clause, under which you pay 20 to 30% of the bill yourself.
How Do You Choose the Right Policy?
Start with a basic policy, but start now. Do not wait until you retire, or until you fall ill. You can raise the cover later, as your needs and budget allow.
A Word of Caution
Be careful when comparing policies online. Many websites and apps that look like neutral advisers actually push the policies of companies that pay them a commission. Use government-recognised portals, or consult a trusted, independent adviser. One such independent platform is beshak.org, which gives unbiased advice and does not sell insurance.
Beware of dishonest agents. Some promise impossible benefits or returns from insurance. Keep your documents safe, read every term carefully, and insist on complete transparency.
What If You Never Make a Claim?
That is truly good news! Just as we are relieved when the airbags in our car never have to open, you should be glad that your family has stayed healthy. Many insurers reward claim-free years with a no-claim bonus, which raises your cover year after year.
An Encounter in My OPD
I had an interesting experience recently. A patient came to my OPD and asked to be admitted. When I asked why, he said, “Doctor, I have been paying the insurance premium for five years and have not used it even once. It pays only if I am admitted to hospital. I feel all my money has gone to waste.”
I had to explain that insurance exists to protect you from unexpected medical expenses and to give you peace of mind, not so that you can deliberately “recover” the premium you paid.
Admissions made only for tests or check-ups, without a significant illness behind them, are rejected by insurers. When a doctor advises admission, it is only because the situation calls for it.
What Is Usually Not Covered
Besides this, there are certain situations in which claims are rejected as per the policy terms. These include illness caused by alcohol or drug abuse, suicide attempts, injuries from dangerous sports or adventure activities, and cosmetic treatments that are not medically necessary (plastic surgery after burns is an exception).
Routine health check-ups without an illness, dental treatment (covered only when it follows an accident) and congenital diseases are also usually excluded.
For the Safety of You and Your Family
Health insurance is a financial first-aid kit for your family.
You hope you never need it, but when the need arises, just having it is a great comfort. It helps you face the uncertainties of life with dignity, and it protects your savings.
Buying health insurance is an act of care and responsibility, for yourself and for your family.
The right time to take it is before you need it.
The Do’s and Don’ts of Health Insurance
Do
- Declare every pre-existing condition honestly when you buy the policy.
- Compare policies on government-recognised or neutral advisory platforms.
- Buy early, while you are young and healthy.
- Renew your policy without a break, so that you keep your continuity benefits.
- Check the insurer’s claim settlement ratio on the IRDAI website.
- Read the terms carefully, and know what is covered and what is not.
- Choose a sum insured that fits your family’s needs.
- Use the policy for preventive check-ups, if it offers them.
- Review your policy every few years.
- Look into top-up policies.
Don’t
- Don’t hide any illness or past medical history when you buy the policy. This is the most important point of all.
- Don’t rely only on your employer’s insurance or other small covers.
- Don’t wait until old age or illness to buy a policy. Premiums rise with age, and cover may be restricted.
- Don’t ignore sub-limits or room rent limits. They can reduce what your claim pays.
- Don’t choose a policy only because its premium is the lowest. The cheapest is not always the best.
- Don’t assume every policy covers OPD or maternity costs. Check carefully.
- Don’t fall for impossible promises from agents. Always verify.
- Don’t feel bad that you never made a claim! It is a sign of good health.
- Don’t expect financial returns from your health insurance! It is there to protect you in an emergency, and to give you peace of mind.
Insurance Ombudsman: Free Help for Policyholders
If, despite every precaution, your claim is rejected unfairly, help is at hand.
The Government of India has set up the Insurance Ombudsman, an independent authority, to settle disputes between policyholders and insurance companies. If your insurer rejects a genuine claim without proper reason, or delays settling it, you can approach the Ombudsman. The process is completely free, and you do not need a lawyer.
Office of the Insurance Ombudsman, Bengaluru (for Karnataka)
Address: Jeevan Soudha Building, PID No. 57-27-N-19, Ground Floor, 19/19, 24th Main Road, JP Nagar, 1st Phase, Bengaluru 560 078
Phone: 080-26652048, 080-26652049
Email: bimalokpal.bengaluru@cioins.co.in
How to Approach the Ombudsman
- First, file a complaint with your insurance company, and allow it at least a month to resolve the matter.
- If the insurer rejects your claim, or does not reply within 30 days, you can complain to the Ombudsman within one year of the insurer’s final reply, or if no reply comes at all.
- Forms, guidelines and detailed information are available on the IRDAI website (irdai.gov.in) and the Council for Insurance Ombudsmen portal (cioins.co.in).
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