Health Insurance Checklist: 15 Things to Check Before Buying

Before buying health insurance, check ten core terms: the sum insured, room rent limits, waiting periods, co-payment, disease-wise sub-limits, network hospitals, restoration and no-claim bonus, exclusions, the insurer's claim record and the premium you can sustain for life. Most claim surprises come from these clauses, not from the headline cover. The checklist below covers each one, with the IRDAI rules that apply as of October 2026.

Rules every policy must follow (as of October 2026)

IRDAI's Master Circular on health insurance (May 2024) and its policyholder-protection rules set a floor that every insurer must meet:

These are the minimum standards. Individual policies can be more generous, so compare the actual wording.

The 15-point health insurance checklist

1. Sum insured

Choose cover that matches hospital costs in the city where you are likely to be treated. A single serious hospitalisation in a metro private hospital can cost several lakh rupees. Many families choose ₹10 lakh or more as a base, and use a super top-up for larger cover at lower cost.

2. Room rent limit

This is the most common source of unexpected deductions. Some policies cap room rent at a percentage of the sum insured (for example 1% a day for a normal room). If you take a costlier room, the insurer may reduce related charges in the same proportion. Prefer "no room rent limit" or "single private room" cover.

3. Waiting periods

• Initial waiting period: usually 30 days for illnesses (accidents are typically covered from day one).
• Pre-existing diseases: up to 3 years maximum, often less.
• Specific diseases and procedures (such as cataract, hernia, joint replacement): typically 1 to 3 years, as listed in the policy.
• Maternity, where offered: often 9 months to several years.

If you have diabetes, hypertension or a thyroid condition, a shorter PED waiting period is worth paying for.

4. Co-payment

A co-pay means you pay a fixed share of every claim, for example 10% or 20%. Policies for senior citizens often include one. A lower premium with a high co-pay can cost more when you actually claim.

5. Disease-wise sub-limits

Some policies cap payouts for specific treatments (cataract, knee replacement, certain cancers) regardless of the sum insured. Look for "no sub-limits."

6. Network hospitals

Check whether the hospitals you would actually use are in the insurer's cashless network. Reimbursement is still available elsewhere, but you pay first and claim later.

7. Pre- and post-hospitalisation cover

Typical cover is 30 to 60 days before and 60 to 180 days after hospitalisation for related tests and medicines. Longer is better.

8. Day-care procedures

Modern treatments like chemotherapy, dialysis and cataract surgery often need less than 24 hours in hospital. Make sure all day-care procedures are covered.

9. Restoration (recharge) benefit

If your sum insured is used up, restoration refills it for later claims in the same year. Check whether it applies to the same illness or only to unrelated ones.

10. No-claim bonus

A claim-free year can increase the sum insured, often by 10% to 50% a year up to a cap. Check whether the bonus is reduced after a claim.

11. Exclusions

Read the permanent exclusions list. Common ones include cosmetic surgery, self-inflicted injuries and some experimental treatments. AYUSH treatment in recognised hospitals is generally covered up to the sum insured, but read the conditions.

12. Consumables and non-payable items

Gloves, masks, PPE kits and some disposables are often not paid unless you buy a "consumables cover" add-on. These can add 5% to 10% to a bill.

13. Claim record and service

Look at the insurer's incurred claim ratio, claim settlement record and complaint data in IRDAI's annual reports, over several years rather than one.

14. Renewability and premium increases

Health policies are renewable for life; insurers cannot refuse renewal because you made claims, except in cases like fraud or non-disclosure. Premiums do rise with age bands, so check the premium table for age 45, 55 and 65 too.

15. Tax benefit

Under the old tax regime only, premiums qualify for deduction under old Section 80D (now Section 126 of the Income-tax Act, 2025): up to ₹25,000 for self, spouse and children (₹50,000 if a senior citizen), plus up to ₹25,000 for parents (₹50,000 if senior citizens), as of FY 2026-27. A preventive health check-up of up to ₹5,000 is included within these limits. Compare regimes with our income tax calculator.

Worked example: how a room rent cap shrinks a claim

Illustrative figures. Sum insured: ₹5 lakh, with room rent capped at 1% of sum insured, i.e. ₹5,000 a day. You take a room costing ₹8,000 a day for 4 days.

Hospital bill:

• Room: ₹8,000 × 4 = ₹32,000
• Doctor fees, OT, nursing and other room-linked charges: ₹1,00,000
• Medicines, implants and diagnostics: ₹68,000
• Total: ₹2,00,000

Proportion allowed = ₹5,000 ÷ ₹8,000 = 62.5%

Payable by insurer:

• Room: ₹5,000 × 4 = ₹20,000
• Room-linked charges: ₹1,00,000 × 62.5% = ₹62,500
• Medicines, implants and diagnostics: ₹68,000 (under IRDAI's standardisation norms, proportionate deduction generally does not apply to these items; confirm in your wording)
• Total paid: ₹1,50,500

You pay: ₹49,500, even though the bill was well within the ₹5 lakh sum insured. A policy without a room rent cap would have paid the full ₹2 lakh, subject to other terms.

Documents and disclosure

When filling the proposal form:

• Disclose every existing illness, medication and past surgery.
• Disclose smoking, alcohol and tobacco use honestly.
• Mention existing health policies.

Non-disclosure is one of the top reasons claims are rejected in the first five years. Our guide on why insurance claims get rejected explains the others.

Should you buy individual or floater cover?

For a young family, a family floater is usually cheaper. If parents are older or have health conditions, separate policies often work better. See individual vs family floater health insurance for the full comparison. If you are covered at work, read is employer health insurance enough before deciding how much personal cover to buy.

If something goes wrong

If a claim is delayed or rejected, complain first to the insurer's Grievance Redressal Officer. Insurers are expected to resolve complaints within 14 days. If not satisfied, escalate through IRDAI's Bima Bharosa portal (bimabharosa.irdai.gov.in) or toll-free 155255, and approach the Insurance Ombudsman (cioins.co.in) for disputes up to ₹50 lakh, within one year of the insurer's final reply. Bima Bharosa does not automatically forward complaints to the Ombudsman, so file there separately if needed.

Key takeaways

• Check sum insured, room rent, waiting periods, co-pay, sub-limits and network hospitals before price.
• IRDAI caps the PED waiting period at 3 years, sets a 5-year moratorium, and requires cashless decisions within 1 hour and discharge approval within 3 hours (as of October 2026).
• A room rent cap can cut a ₹2 lakh claim to about ₹1.5 lakh, as the illustrative example shows.
• Individual health policies carry no GST since 22 September 2025; the tax deduction is old-regime only.
• Disclose all health conditions honestly to protect future claims.
• Complaints go insurer GRO → Bima Bharosa → Insurance Ombudsman.