When it comes to health insurance plan, one of the most common questions people ask is: “What exactly does my policy cover?” Most people who have bought health insurance cover not even aware benefits of health policy. It is only family members or friends get hospitalized or when someone known health claims is rejected, they get to know their health policy. While most insurers advertise a range of benefits, the fine print can often be confusing — and overlooking the details might leave you with unexpected expenses.
In this comprehensive article, we’ll explore everything your health insurance does and does not cover in India. From hospitalisation expenses to daycare treatments, and from maternity benefits to alternative therapies, we’ll break it down in simple, everyday language.
So, if you’re trying to understand what your health insurance plan really offers, this article is your one-stop resource.
1. Hospitalization Expenses (Inpatient Care)
This is the core benefit of every health insurance cover.
If you are admitted to a hospital for more than 24 hours for medical treatment, your insurer will typically cover:
- Room rent charges
- Nursing expenses
- Doctor’s fees
- ICU charges
- Surgery costs
- Medicines and consumables
- Operation theatre charges
Important Tip: Most policies have a room rent limit (like Rs.5,000/day or 1% of sum insured). If you choose a more expensive room, your entire claim might get prorated, which means you’ll receive a partial reimbursement.
2. Pre-Hospitalization Expenses
Most health insurance plans cover medical expenses incurred before hospitalization, typically 30 to 60 days in advance.
This includes:
- Doctor consultations
- Blood tests and diagnostic scans
- Medication and follow-ups
Example: If you’re diagnosed with dengue and admitted for 3 days, any consultation, blood test or medication taken up to 30 days before hospitalization will be covered.
3. Post-Hospitalization Expenses
These are expenses incurred after you are discharged, usually up to 60 or 90 days, depending on the policy.
It includes:
- Follow-up doctor visits
- Medicines
- Lab tests and investigations
This is especially important for surgeries, recovery-based treatments, or chronic illness follow-ups.
4. Daycare Procedures
Gone are the days when every treatment required 24 hours of hospitalization. Many modern treatments are now completed within hours — and these are covered under daycare procedures.
Common examples include:
- Cataract surgery
- Dialysis
- Chemotherapy
- Radiotherapy
- Tonsillectomy
- Angiography
Most policies cover over 150 to 500 daycare procedures. Check your policy document for the full list.
5. Domiciliary Hospitalization (Home Treatment)
If you cannot be moved to a hospital due to your condition or lack of hospital beds (which happened during COVID-19), your treatment at home may still be covered under domiciliary hospitalization.
But there are conditions:
- The treatment must be medically necessary.
- It must be a case where hospitalization would have happened, if not for external limitations.
- Usually requires approval from the insurer.
6. Ambulance Charges
Most health insurance plans cover ambulance expenses during emergency hospital admissions.
- Usually capped (e.g., Rs.1,000 to Rs.5,000 per hospitalization)
- Some comprehensive plans even cover air ambulance for critical conditions (typically for high sum insured policies)
Always check your policy limit for this.
7. Maternity and Newborn Cover
Maternity cover is not available by default in most basic policies — but it’s included in some corporate group plans and high-end individual or family floater plans.
If included, it may cover:
- Delivery expenses (normal or C-section)
- Pre-natal and post-natal care
- Newborn baby cover (up to 90 days)
Waiting Period: Maternity benefits usually have a 2 to 4 year waiting period before you can claim.
8. AYUSH Treatment (Ayurveda, Yoga, Unani, Siddha, Homeopathy)
Thanks to IRDAI’s guidelines, many insurers now cover AYUSH treatments under health insurance plan.
Conditions:
- Treatment must be done in a government-recognized AYUSH hospital
- There’s usually a cap on coverage (e.g., up to 25% of the sum insured)
If you prefer alternative therapies, make sure your plan includes this.
9. Mental Health Coverage
Since 2018, IRDAI has made it mandatory for insurers to include mental health in health insurance plan.
Policies may include:
- Psychiatric consultations
- In-patient mental illness hospitalization
- Counselling and therapy sessions
Coverage is still evolving, and exclusions may apply (e.g., OPD therapy may not be fully covered). Always verify the scope with your insurer.
10. Organ Donor Expenses
Organ transplant coverages are given in health insurance plan which cover:
- Expenses for the donor’s surgery
- Hospitalization of the donor
However:
- Post-surgical treatment of the donor is usually not covered.
- Some policies don’t cover organ transplant if not medically necessary.
11. Vaccinations and Preventive Health Check-ups
Some health insurance plans, especially premium ones, cover:
- Annual health check-ups
- Vaccination costs (for children or travel)
- Diabetes screening or cancer tests
These benefits are often available once a year and may depend on your claim history or renewal bonus.
What is NOT Covered in Most Indian Health Insurance Plans?
While your health insurance plan may offer wide-ranging coverage, there are some common exclusion you should be aware of:
- Pre-existing diseases (usually covered only after a waiting period of 2–4 years)
- Cosmetic or plastic surgery
- Dental and vision treatment (unless accident-related)
- Self-inflicted injuries or substance abuse or alcohol abuse
- Infertility treatment or IVF
- Unproven or experimental treatments
- Non-medical expenses (e.g., registration fees, toiletries, gloves)
Knowing these exclusions helps you avoid surprises during claim settlement.
How to Know Exactly What Your Policy Covers?
Here’s how you can check your health insurance plan cover in detail:
- Read the policy brochure and policy wordings carefully
- Check for sum insured, sub-limits, and waiting periods
- Ask your insurer for a welcome kit or digital copy of inclusions
- Use the insurance company’s app or website portal to track coverage
- Speak to a health insurance advisor or agent if you have doubts
Conclusion: Know Your Policy, Protect Your Health
Understanding what your health insurance plan cover are essential to making the most of your plan and avoiding unexpected costs when you need care.
Let’s recap:
- Your policy generally covers hospitalization, pre/post expenses, daycare procedures, and even AYUSH treatments.
- Add-ons and top-ups can enhance maternity, mental health, or critical illness coverage.
- Be aware of exclusions and waiting periods to avoid claim rejection.
- Always review your policy documents and reach out to the insurer for clarification.
The better you understand your coverage, the better you can plan for life’s medical uncertainties — without financial stress.
