Health insurance is an umbrella that promises to protect you when it rains. Unfortunately, only after it starts pouring will you notice the leaks – some minor, some humongous. Hence it always pays to be prepared for the leaks, just in case.

I had a personal experience, when a family member was faced with a serious illness. Along the way I discovered some must-haves and good-to-haves. Here are a few: 

Fine print always surprises 

First, the fine print always surprises you. At some point, we will have to accept that there is no way we will be fully aware of all the nuances of a health policy. In our family’s case, we realised only when we made a claim that any treatment involving immunotherapy or monoclonal therapy would be eligible for no more than a miniscule portion of your sum insured, as per norms. The fine print did mention this in the policy document but then, rarely do we read all of the fine print. And, would we have refused a policy even if we had noticed this condition? Unlikely. After all, when we are healthy, we feel serious illnesses only affect ‘others’, never ourselves. 

The suggestion here would be to take a policy specific to a particular illness. Our reaction to a family member’s suggestion made two years earlier, that we take out separate policies to protect against cancer or cardiac risk, was to ask ourselves how many such policies could we take, especially if the existing generic policy covers all illnesses? With the benefit of hindsight, I would still go for a policy specific to cancer treatment and/or cardiac treatment, in addition to a generic health insurance policy. We have all seen how common cardiac issues have become. 

A breast oncology specialist in the family practising in the UK says that as a thumb rule, cancer used to occur in one in five people earlier and that she wouldn’t be surprised if that becomes one in two in the near future! So, would you suggest a cancer cover is highly recommended if the premium is affordable?

The other thing about fine print is that there are workarounds. For example, I did not know that my policy allowed me only 3 per cent of sum insured as daily maximum room rent. At ₹2 lakh sum insured, the policy did not fully cover the room rent of about ₹10,000 at a popular city hospital.  

Proportional coverage – a curve ball

While we were prepared to shell out the remaining for the room rent for an 80-odd day stay in hospital across 4 admissions in a six-month period, where we were impacted most was that the policy only allowed proportional coverage for other charges such as doctor fees, investigation and treatment charges. This means that if the policy covered only 60 per cent of the room rent, it would cover only 60 per cent of all other charges. With all the exclusions (such as caregiver’s meals, disposables used in investigation or treatment, etc), the settlement at any point in time came to only 50 per cent of our total expenses. That too, because we had two insurance policies, one via my employer and one personal policy. 

Only when the personal policy came up for renewal the subsequent year, did I become aware that an extra premium would allow for delinking the other charges from the room rent coverage and give you full coverage against those charges. So, it would be worth checking if your current policy has a clause similar to proportional coverage, in which case it would be worth signing up for that extra premium that delink room rent and other charges.

Knowledgeable agent is critical

It always helps to have a knowledgeable insurance agent who looks to your interest. When I bought a car a few years ago, I emphatically refused the insurance offer from a highly perseverant dealer as I did not wish to move away from my insurance agent, a senior citizen, who had been handling both my motor and family health insurance policies for a decade prior. At the time, I could not have imagined that a couple of years later the same agent would help me get a couple lakh rupees that was rightfully due to me from the insurance firm, but was unfairly denied due to an error on their side. At a time when I was personally too tired to fight, the agent took it upon himself as explained below.

Callousness 

Now, with any serious illness of a loved one comes emotional and financial trauma. Be prepared to add to these the trauma of having to deal with callous insurance professionals if you are unlucky. They do not intend to make life difficult for you, but it’s not clear why many a time there is such a lackadaisical approach to claims. 

For expenses for our first stay in hospital of about 25 days, we spent mostly out of pocket because of some confusion regarding two policies being submitted for one patient. We applied for reimbursement for the full amount after we exited the hospital in January 2024. There was no response despite repeated requests until May. Meanwhile, necessity for more in-patient treatment arose and those claims were partly approved for cashless claims via the hospital on the day of discharge after each round of treatment. 

When we escalated our original reimbursement claim with the senior management of the insurance firm, the third-party administrator  rejected the claim. When asked for the reason, we were told that the reimbursement would have been possible for the base policy but now, after several rounds of treatment, the base policy had been exhausted and the top-up policy could not be used for reimbursement claims. 

At that point, the entire family was at the end of our tether. We did not have the energy or inclination to fight for the ₹2 lakh or so due to us. This is when our insurance agent took the matter into his hands, behaved like a family elder, dragged me to the insurance office and presented his argument strongly – had the company settled the original January 2024 reimbursement claim in time, it would well have fallen under the base policy. The remaining rounds of treatment would have then been covered under the top-up policy instead of getting adjusted under the base policy. If the insurance company delayed response, leave alone the decision, from January to May of that year, why should the claimant be penalised for no fault of theirs? Post a strong and well presented argument from the agent, the insurance company ended up reimbursing whatever was left of the sum assured at the time. 

This neither struck me nor would I have taken this up without my agent’s insistence. But the insurance company ought to have acted on empathetic lines without being reminded.  

After all this trauma, you might wonder if it is worth opting for health insurance. My answer would still be an emphatic ‘Yes’. In this instance, two insurance policies helped cover about one-third the total amount spent in medical treatment. When the total sum is large, 33 per cent respite is a great deal. The deal can be better than this if you plan well for the possible leaks in the policy you have signed up for.

Published on May 30, 2026