Summary of this article
Exclusions & waiting periods: Understand what is not covered and how long you must wait before benefits like pre-existing disease or maternity cover become active.
Claims experience: Check the insurer’s claim settlement ratio, turnaround time, and customer feedback to gauge reliability at the time of need.
Network hospitals: Ensure the policy offers cashless access to reputed hospitals you are likely to use, especially in emergencies.
Usability over numbers: A high sum insured matters only if the policy delivers smooth, practical protection during real-life claims.
The beginning of a new year is a good moment to reassess your insurance cover, even if your policy renewal is months away. While evaluating a health insurance policy, policyholders should look beyond numbers and premiums to focus on qualitative checks. What ultimately matters is not the number of covers, but how usable they are in real-life claim situations.
According to insurers, the first thing to check is exclusions.
“Every policy has a list of exclusions or treatments that are not covered. It may be a pre-existing condition for a certain period or a specific procedure, such as dental procedures or cosmetic surgery. You should know what the exclusions are so that you will know where the policy aligns with your health profile and anticipated risks, rather than leaving gaps that could lead to claim denials,” says Amarnath Saxena, Chief Technical Officer- Commercial, Bajaj General Insurance Limited (formerly known as Bajaj Allianz General Insurance Company Limited).
Equally important are waiting periods, which dictate how long one must hold the policy before certain benefits become available.
For example, pre‑existing conditions often carry a waiting period of 2 to 4 years, while maternity benefits may require 3 to 4 years. If these waiting periods overlap with foreseeable needs, say, a planned childbirth or ongoing treatment, the policy may not be adequate despite a high sum insured.
Venkatesh Naidu, CEO at BajajCapital Insurance Broking Ltd, says the experience of a policy is shaped by what lies beneath that number. “Exclusions and waiting periods deserve close attention. A policy may look affordable, but if it excludes common conditions or stretches waiting periods across several years, the protection can feel inadequate when a real health issue surfaces. These details matter most not at purchase, but at the time of claim,” he says.
Claim settlement has also become equally important to check in.
“A policy is only as good as its ability to pay when needed. Reviewing the insurer’s claim settlement ratio, average turnaround time, and customer feedback provides insight into whether claims are processed smoothly or denied with disputes and delays. A high settlement ratio and transparent processes are indicators of reliability,” informs Saxena.
It is also important to check for network hospitals. Even if the sum insured is generous, the practical benefit lies in cashless treatment at reputable hospitals. Policyholders should verify whether the insurer’s network includes top‑tier hospitals in their city, especially those they would realistically choose in an emergency. A weak or limited network can force out‑of‑pocket payments and undermine the value of the policy.
These qualitative checks ensure a health insurance policy really translates into real protection.
