Certain claims will have a limit to the amount of money that is paid by the Insurer

Sub-limit is a disease wise limitation on the claim amount. The amount of claim for a specific disease will be limited as per terms of the policy. In other words, it places a maximum limit of amount payable for treatment of one type of disease. Sub-limits are generally included for diseases such as hernia, cataract, maternity and other ailments or procedures, depending on the Insurer & their corresponding policy terms.


This is the procedure by which the policyholder pays for treatment upfront to the Hospital from their own pocket, and claim it later from the Insurer. After submission of bills, the Insurer verifies the bills and pays the amount if found in order.

Co-Payment or Co-pay

20% Co-pay will mean that Insurance company will settle 80% of the claim amount..

If co-pay is opted in an insurance policy, the insured has to pay a fraction of the claim amount. Co-payment is shown as a percentage of the total claim amount. If co-pay is included in the Insurance Policy, the premium will be lower.

For example, if the total hospital expenditure is ₹1,00,000/- and if the co-pay is agreed at 20%, then the insured has to pay an amount of ₹20,000/- and the balance of ₹80,000/- will be paid by the Insurance Company.

Third Party Administrators

IRDAI licensed Third Party Administration process the claims under health insurance on behalf of the Insurance Companies, on a fee-for-services basis. Their responsibilities typically include claims administration, loss control, co-ordination for cashless claim settlements and risk management consulting.

Waiting Period

Certain diseases will have a waiting period before any claims are accepted.

Waiting period for a specific disease/ailment is the period from the inception of policy within which claims will not be accepted for any treatment related to that disease. The policy holder has to pay the premiums for the waiting period and such claims will be accepted after the waiting period is over.

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Network Hospitals

Insurance Companies tie-up with leading hospitals with pre-agreed rates for treatments..

Hospitals and other health care providers contracted to provide services to customers of the insurance companies on a pre-agreed fees are called Network Hospitals or Provider Network. If the policyholder undergoes treatment in any of these network hospitals, there is no need for the Policyholder/ Insured to pay hospital bills, which is called ‘Cashless Facility’.

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Pre and Post Hospitalisation cover

Your health insurance will cover expenses related to Doctor’s fees, Medicine and diagnostic tests before and after hospitalised treatment

Pre-hospitalisation Cover

Pre-hospitalisation expenses include various charges related to medical diagnostic tests and consulting doctor fees before you are hospitalised. The doctors/physicians conduct tests to accurately diagnose the disease/ailment before advising hospitalisation and treatment.

In most cases, expenses incurred for 30 days prior to your hospitalisation are covered under pre-hospitalisation cover. Depending on the health insurance plan taken the pre-hospitalisation cover is extended for a period of 30 days to 60 days prior to hospitalisation.

The bills related to such pre-hospitalisation expenses along with prescribed doctor’s certificates can be submitted to the Insurer and get reimbursed.

Post hospitalisation Cover

Post hospitalisation expenses include various charges related to medical diagnostic tests, prescribed medicines and consulting doctor fees after you are discharged from the hospital. The doctors/physicians advise tests and medicines after the hospitalised treatment to monitor your recovery.

In most cases, such expenses incurred after your discharge from the hospital are covered under post hospitalisation cover. Depending on the health insurance plan taken, the post hospitalisation cover is extended for a period of 60 days to 180 days after hospitalisation.

The bills related to such post hospitalisation expenses along with discharge summary and prescribing doctor’s certificates and test reports can be submitted to the Insurer and get reimbursed.