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Common Restrictions in Senior Citizen Health Insurance Policies

By Juhi Walia
06 September 2022, 10:45 AM

Senior citizen health insurance refers to health insurance policies covering expenses incurred on medical treatments for people over 60. Citizens that fall under this bracket often usually have to deal with multiple health issues as they age. The Covid-era that we're now living in has increased susceptibility to falling sick, more so for elderly citizens. Therefore, having a reliable and dedicated health insurance plan for senior citizens is important.

With the mounting healthcare costs, it's crucial to be financially prepared in advance to handle any medical emergencies, diseases, or other health conditions. This article takes a deep look at the healthcare policies for senior citizens in India. The goal is to understand if these policies are suitable or restrictive and require changes. It's better to be aware of any restrictions beforehand so they don't come as unpleasant surprises in critical times.

Common Restrictions in Senior Citizens' Health Policies


Sub-limit refers to the maximum percentage of the total amount insured that the health insurance company is liable to pay for each medical expense. Each different medical expense can have a different applicable sub-limit. The different expense categories for which sub-limits exist are hospital room charges, doctor's fees, nursing costs, specific disease treatment expenses, medication costs, outpatient consultation costs, etc. 

For example, you've purchased an INR 10 lakh insurance policy plan. It may have a sub-limit of 1% for hospital room expenses. This would mean that the maximum amount you can claim for your room charges is INR 10,000 per day. Similar limits may be applicable for other types of expenses too. 

This restrictive feature is present in insurance policies other than those for senior citizens, too, like in family floater health insurance plans. It's important to take note of all the expenses for which sub-limits exist. It's how you can calculate the cumulative amount that you'll be responsible for paying. If you choose a policy with no sub-limits clause, the premium amount may go up.

Co-payment Clause

Regardless of which senior citizen policy you opt for, co-payment is mandated by all of them. Co-payment means you, as a policyholder, will be required to pay a certain portion of the total insurance amount you're claiming. This includes expenses related to certain treatments, hospitalisations, and diseases. You can't count on your insurance policy to bear the full amount of these medical expenses.

When choosing a policy, you want to consider how much co-payment is expected of you. The last thing you want is the unreasonable burden of expenses on yourself. So, it's important to discuss with your insurer if they can provide any exemptions on the co-payment. For example, see if there's an option where you can pay a higher premium to avoid co-payment. You could also go for vice-versa, meaning opt for more co-pay and less premium.

You should also clarify if the co-pay percentage can be less in case you get treated at one of the network hospitals. Having clarity on the co-payment terms and conditions is essential, especially if you need health insurance for a surgery that's expensive.

There is no guarantee that the insurer might relax terms on co-payment obligations, but you should do your bit in earnest. That could prompt the insurer to ease co-payment norms in your case.

Pre-Policy Medical Test Obligation

A senior citizen health insurance plan can come with a pre-policy medical test obligation.  In case the test reveals too many conditions, the insurer may hike your health insurance premium. Some cases can even be rejected.

Waiting Period

The waiting period in health insurance refers to how much time you need to wait after buying a policy to claim any coverage. It holds true for insurance policies in general; depending on different cases and insurance policies, this waiting period will vary.

The initial waiting period comes into effect as soon as you buy a policy and is typically for 30 days. Barring cases of accidents, policyholders can't apply for any claims during these 30 days. A policy may also have a waiting period for certain surgeries like cataracts and joint replacement. Any coverage for such surgeries can only be availed typically after a year or two. 

Do I Need to Buy a Senior Citizen Health Plan?

Given all the restrictions we just went through, it's natural to question whether it's worth buying a senior citizen health insurance plan. 

Well, if you have a regular health insurance policy you purchased before turning 60, you may not need to buy a senior citizen health policy separately. You can just continue using the regular one for a lifetime through timely renewals. The more time you stick with a health insurance plan, the better. This way, you can finish through different waiting period criteria and start leveraging more claim options.    

But if you've entered your golden years without a health insurance plan so far, a specialised insurance plan for senior citizens is the way to go. Regular health insurance policies could have age restrictions that make you ineligible to apply for them once you've reached a certain age (65+). The maximum age limit for senior citizen health insurance plans can be 75-80 years.


Many policy choices are available today for senior citizens, with some restrictions common across most of them. But some companies may offer more relief than others in these restrictions. Therefore, do your due diligence by delving deep into the fine print. When choosing a senior citizen insurance policy, be mindful of the factors mentioned above. You have to look at everything ranging from what expenses are covered to what limitations there are. It's vital to compare health insurance plans and make the right call. 

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1. Who pays for the pre-policy health checkups for senior citizens?

Usually, these checkups are free if you get them done at one of the hospitals in the insurance company's network.

2. What is the co-payment amount for most insurance policies?

Generally, the amount that policyholders are required to pay is 20% of the insurance amount claimed. In some cases, this 20% co-payment is applicable for all health insurance claims. On the other hand, there also exist policies where your co-payment amount decreases with health insurance renewals. 

3. Is there any insurance coverage for senior citizens with pre-existing diseases?

The insurance policies for senior citizens usually offer coverage for diseases existing before buying the policy. However, there is typically a waiting period of a few years that you'll need to complete before you can leverage this option. Each plan may define a different waiting period. Moreover, there may be a max limit to how much can be claimed for these pre-existing diseases. Another important thing to note is that the list of pre-existing conditions covered may be different for each policy. So, do check the claim amount limitations and the list of covered pre-existing illnesses before signing up. 

4. Do senior citizen plans cover domiciliary treatments too?

Certain policies may provide pre-defined coverage for domiciliary treatments or treatments done at home.  

5. What's excluded from coverage under senior citizen health plans?

There are certain injuries, conditions, and treatments that senior citizen insurance policies don't cover. For example, dental and cosmetic surgeries with exceptions, injuries resulting due to self-harm or war, experimental treatments, etc. Before buying a plan, make sure you're aware of everything that's not included in it. 

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