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Why is Understanding the Fine Print of Health Insurance Crucial?

By Vikas Chandra Das
15 November 2022, 2:45 PM

Many people find it helpful to get health insurance since it offers them a variety of advantages. But when you decide to use your health insurance, you can frequently encounter uncomfortable situations because most health insurance policies bury actual prices in the small print. In addition, because you don't understand how health insurance works, your claims may get rejected. So, before buying a policy, you should be aware of its terms and conditions.

Here, we'll concentrate on a few tiny print provisions of your health insurance that you should be aware of when choosing a plan. If you are unsure how to pick the right health insurance plan, this article will help you by highlighting the terms and conditions you should be looking for.

Pre and Post-Hospitalisation Costs

Most people are unaware of this perk an insurance company provides to policyholders. According to pre-hospitalisation costs, the insurance provider reimburses all out-of-pocket costs.

Before prescribing a course of treatment, doctors may order many tests to accurately diagnose a patient's ailment. Depending on the insurance provider, the days covered by pre-hospitalisation insurance might range from 30 to 60 days.

Post-hospitalisation expense refers to the costs incurred after you are released from the hospital. In addition, the consulting doctor may occasionally recommend tests to determine a patient's progress. The number of days covered varies amongst insurance companies.

It is crucial to note that while consulting fees and diagnostic costs are reimbursed, therapies like acupuncture and naturopathy are not.

Waiting Period 

Most people who intend to get health insurance coverage are unaware of what a "waiting period" is. However, one of the provisions may impact the likelihood of obtaining benefits as soon as the insurance policy is purchased. All insurance companies have a waiting period, which is the period during which you are not eligible to receive benefits from the insurance provider.

Whatever occurs, you will have to wait until the "waiting period" is over before filing a claim. There are three different waiting periods: initial, disease-specific, and pre-existing conditions.

In the initial waiting period scenario, you won't get any assistance if you become ill between 30 and 90 days after the policy's start date. Pre-existing conditions would come with a waiting period of up to four years. The waiting time from the start of the policy may last up to two years for specific ailments.

Room Rent Capping 

A little provision that is tucked away in a health insurance policy's fine print is the room rent limit. The most headaches could come from this clause. Your health insurance policy states you are entitled to the maximum daily rate.

A dilemma presents itself when you learn that the hospital offers superior rooms. If you rent a more expensive room than the amount covered by the policy, you are responsible for paying the difference. But there's more!

All additional costs you incur will be assessed as per the type of room. The insurance company will also reduce all other hospital expenses, except those with MRP, after deducting the room costs over your eligibility. Therefore, before choosing a hospital room, you must be sure of your health insurance coverage limit.

Age Brackets and Renewal Ceasing 

It may happen while purchasing health insurance that you might not consider the age of policy renewal. The renewal ceasing age is when the insurer will no longer accept your application for coverage. It is better if the age at which renewal ceases is higher. You should know the oldest age at which you can renew a current policy.

Before selecting the coverage, discuss this subject in detail with your insurance company. A policy renewal reminder is not required from the insurance provider. However, it's a good idea to renew insurance before it expires. If you don't renew your policy on time, your coverage expires.


Insurance companies may not cover certain diseases throughout your policy term. These include dental work, infertility treatments, AIDS, and many more. Furthermore, the exclusion list varies between insurance companies. By carefully reading the policy document, you can learn about the conditions not covered by the insurer.

Cashless Facility

In a cashless facility, your hospital costs are directly cleared by the insurance company with the network hospital; you are not required to pay anything for your treatment. Hospitalisation without cash, however, is hardly cashless. Consequently, you might not always benefit from a cashless facility. Check these scenarios- 

  • You might not be admitted to the hospital in your insurer's hospital network in the event of a medical emergency. Therefore, you must first pay your bills before requesting compensation.
  • When you visit your local network hospital for an unanticipated treatment, your treating physician may not have been able to correctly diagnose your condition, which prevents the hospital from giving your insurer the necessary information. Because of this, the insurer may partially or entirely reject your claim for lack of knowledge. This implies that you must contribute a particular sum.
  • Cashless hospitalisation can take a long time to settle in some facilities. But you can't afford to waste time if you're being critical. Consequently, you need to make an upfront payment.
  • If you and the doctor treating you don't complete a pre-authorisation form by the deadline, it won't be received by your insurance company in time. Once you are admitted to the hospital, you must notify your insurance provider. Your insurance company will assess if the admission will be cashless once you complete the pre-authorisation form.


Before buying health insurance coverage, be aware of its terms and conditions. Keep looking at them every time before deciding. If you still don't understand how to purchase medical insurance or don't have enough information, you should speak with a financial professional.


1. What are the insurance clauses?

Sections of an insurance plan are called "clauses." A clause is an essential feature of an insurance contract since it includes a specific provision to protect the policyholder's and the insurance provider's interests. The clauses include specific guidelines for payout and contract termination.

2. What is the reasonable and customary clause?

Claims may also be impacted by the ordinary, customary and reasonable (UCR) provision designed to prevent service abuse. By using this clause, insurers can limit the claim payment amount to what they think is appropriate. This clause, according to experts, causes many claims to be settled only in part.

3. What are the basic parts of an insurance policy?

Insuring agreement, exclusions, declaration page and conditions.

4. What are the two principal forms of health insurance?

Private and public, and government health insurance are the two main categories.

5. What does a health insurance contribution clause mean?

In essence, contribution refers to an insurer's right to request assistance from other insurers who are liable to the same insured to split the expense of an indemnity claim on a pro-rata basis. Any benefit offered based on fixed benefits shall not be subject to this section.

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