🩺 Health Insurance & Your Rights — What Every Policyholder Must Know

🩺 Health Insurance & Your Rights — What Every Policyholder Must Know

Empowering my customers with the right knowledge for stronger, safer decisions.

Health insurance is not just a financial product—it is a lifeline during medical emergencies. But as a policyholder, understanding your rights, coverage, exclusions, and claim rules is equally important. The recent Business Line feature highlights how IRDAI regulations protect you and ensure fair practices by all insurers.

Here is a simple, clear breakdown of the key points you must know as a health insurance customer:

✅ 1. Insurance Covers Only Medically Necessary Hospitalization

Your insurance will pay only for treatments that require medically necessary hospitalization, meaning:

Hospital stay of minimum 24 hours (except day-care procedures)

Treatments that follow standard medical guidelines

Procedures recommended by a registered doctor

Unnecessary tests, luxury rooms, or non-medical expenses may not be covered.

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✅ 2. Pre-Existing Diseases (PED): Always Disclose!

A pre-existing disease means any medical condition you had before taking the policy.

Examples: diabetes, BP, thyroid, asthma, old surgeries, etc.

Tip: When in doubt — disclose it.

Non-disclosure of PED is the No.1 reason for claim rejections.

IRDAI rules:

Waiting period for PED is up to 3–4 years.

Once the waiting period is completed, the insurer cannot deny claims related to that illness.

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✅ 3. Moratorium Rule – Your Policy Becomes “Error-Proof” After 5 Years

If you have continuously renewed your policy for 5 years, the insurer cannot reject claims based on non-disclosure unless fraud is proven.

This gives long-term customers strong protection.

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✅ 4. Claims Cannot Affect Your Premium or Renewals

Insurance companies cannot increase your premium just because you made a claim.

They also cannot deny renewal except in cases of fraud or non-payment.

This rule protects senior citizens and those with repeated hospitalizations.

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✅ 5. Know the Exclusions Clearly

Every policy comes with exclusions—conditions that cannot be covered.

Common exclusions:

Cosmetic procedures

Fertility / IVF

Dental treatments without accidents

Weight-loss surgery

Admission only for diagnosis

OPD consultations (unless covered separately)

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🚫 What Insurers Cannot Exclude (IRDAI Protected List)

As per IRDAI, insurers must cover these conditions and cannot exclude them:

Epilepsy

Cataract

Alzheimer’s Disease

Alzheimer’s & Parkinsonism

Mental illnesses

HIV / AIDS

Heart disorders

Hypertension

Diabetes

Injuries due to accidents

This list protects customers from unfair denial of important medical conditions.

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🚫 What Insurers Can Legally Exclude

Some conditions may be excluded under Indian regulations:

Congenital anomalies

Cosmetic surgery

Sex-change treatments

Infertility treatment

Substance abuse treatment

Hospitalization without medical need

Non-allopathic treatments (unless covered)

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🔍 6. Always Read Sub-Limits & Room Rent Caps

If your policy has a room-rent limit (Example: ₹3000 per day), choosing a higher room may increase your bill proportionally and reduce the claim amount.

I can help you review whether your policy has such limits.

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⭐ Why This Matters for You

Understanding IRDAI rules protects you from:

✔ Claim rejection

✔ Unfair charges

✔ Wrong exclusions

✔ Miscommunication during hospitalization

As your insurance consultant, my goal is to ensure you receive maximum benefits and make informed decisions.

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🙋 Need Help Understanding Your Policy?

Share your:

Policy copy

Age

Existing medical conditions

I’ll help you review coverage, exclusions, room rent limits, waiting periods, and recommend the best upgrades if needed.

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Your health is your wealth — and your rights protect both.

Feel free to message me anytime for guidance on health, life, or general insurance.