Understanding the True value of Health Insurance with Clarity of Policy Limitations

Health insurance policies highlight key benefits and policy features that consumers go through before taking the decision to purchase. However, it is important to also go through policy limitations in great detail so when the time comes for raising a claim, it should not come as a rude surprise that one’s claim has been rejected due to policy terms not being met by the insured. In fact, when it comes to claim settlement, policy limitations will matter more than the features offered by a policy. Hence it is important to understand the limitations of your health insurance policy in great detail. In this article we will go over certain clauses laid down by insurers that has limitations to the insured.

Waiting Period:

This refers to the time during which the insurer is not liable to honour a claim. Most insurers impose a window of 30 days during which no claim is payable except in case of an emergency or an accident. This waiting period is also referred to as “Cooling period.” The duration of the cooling window may vary from insurer to insurer.


There are certain illnesses which are covered after a minimum waiting period. This waiting period can range from one to two years based on the policies of the insurer in question. This is referred to as “Exclusions.” Apart from Pre-existing Diseases (PED), certain types of injuries, health conditions, and other forms of medical expenditure are not covered in general by insurers. You will need to assess these aspects. For example, injuries resulting from war, expenses incurred for diagnosis, costs related to cosmetic treatment and cosmetic surgery, cosmetic dental treatment costs, expenses incurred for purchase of eye gear – spectacles, lenses, etc are generally not covered in health insurance policies. By checking this, you can avoid the heartburn of facing a claim rejection later.

Pre-existing Diseases (PED):

Pre-existing Diseases declared by customers also have waiting period. This is subject to the insurer approving the PED as an acceptable risk. The PED waiting period may range from two to three years – this is again based on policies of insurers and may vary.


Essentially, an insurance policy with a co-pay clause requires that the insured pays a percentage of the medical expenses out of their pocket before the insurer comes in and pays the rest of the amount. The percentage ranges between 10 – 25%. So for every Rs.100, the insured pays between Rs.10 – Rs.25 and the insurer pays the remaining amount.

Insurers do not follow a standard procedure while bringing in a co-pay clause. In some cases, the co-pay clause may kick in for claims made for certain ailments specified in the policy. In other cases, the clause may be introduced if the insured undergoes treatment in a certain metropolitan city while the premium amount paid is that of a non-metro. Also, insurers may enforce this clause when the policyholder obtains treatment from a hospital that is not part of the hospital network.


Sub-limits are upper limits imposed on various aspects of hospitalization. Therefore, all costs lower than your sum assured may not be approved by your insurance company. Thus, resulting in unexpected outgo from your pocket.  Sub-limits are imposed to limit claims outgo and is restricted to some common ailments such as piles, hernia, cataract, kidney stones, etc. Of course, the list of ailments and sub-limit factors vary from insurer to insurer. While sub-limits are not largely prevalent for individual health insurance plans, group insurance policies have such limits.

Sub-limits exist for many aspects such as room rent, ambulance charges, ICU expenses, oxygen, etc. Typically, room rent expenses as part of sub-limits are restricted to 1 – 1.5% of the sum assured per day. ICU charges are capped at 2 – 2.5% of the sum assured.
Hope this article helped in throwing light on some of the nitty-gritties of health insurance. It is advisable to go over the policy document in great depth to understand limitations of a policy and how that could impact you at the time of claim settlement. Taking these measures today will save you a great deal in the future. Insurance companies list product details in the product brochure, marketing material and other collateral. You can go over the insurer’s website to learn about product features, exclusions, product terms and conditions, etc. Also, you can ask for additional information if the information already available seems inadequate.