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  • Tax benefitu/s 80D

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What is Health insurance?

Medical insurance or health insurance is an agreement wherein an insurance company agrees to compensate the insured for the medical and surgical expenses incurred during the tenure of the policy. Medical expenses may incur if the insured falls ill, or has an accident that leads to hospitalization. To be eligible to avail of the benefits under the insurance policy, the policyholder is required to pay a specific amount periodically, which is known as a premium. The health insurance premium is decided by the insurance company and the policyholders are required to pay the premium on a monthly, quarterly, half-yearly, or yearly basis, without any lapse, to avoid losing the renewal benefits.

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Types of Health Insurance

Individual Health Insurance Policy

This is a separate policy for each family member with an individual sum insured. The plan has a fixed sum insured, up to which, the insurer will cover the healthcare costs of the policyholder.

Family Floater health insurance

This is one single policy that takes care of the hospitalization expenses of your entire family. The policy has one single sum insured, which can be utilized by any/all insured persons in any proportion or amount subject to the maximum of the policy sum insured.

Senior Citizen Health Insurance

This plan is offered by different insurance companies in India to financially secure those who are aged 65 years and above. They are designed to cover all kinds of medical expenses that are incurred by the policyholder.

Health Insurance Benefits

  • Wide Coverage

    With each passing day, insurance companies are becoming more inclusive and include every category of coverage in their policies. These integrated health policies go beyond offering coverage for an individual, and they provide cover for all the family under a single insurance plan.

  • Extended Renewal

    With the changes introduced by the Insurance Regulatory and Development Authority (IRDAI), the renewal age for health insurance policies can be extended to provide you with more coverage.

  • Cumulative bonus

    This is the reward that insurance companies offer you when you do not raise any claim request during the policy tenure. It is similar to a no-claim bonus in car insurance and the benefits that you can reap vary from insurer to insurer.

  • Cashless Hospitalisation

    The cashless facility can help you to get the best treatment without spending a single penny for it. You have to show the cashless card provided by the insurance company at the hospital, and your insurer will directly settle the bill with the hospital.

  • Portability

    If you are not satisfied with the services that are rendered by your current insurer, you can transfer or port it to another insurance provider. Changing your insurance company generally does not have any impact on your no-claim bonus.

  • Tax Benefits

    If you have purchased a health insurance plan, you can avail of tax benefits under Section 80D; the deduction is applicable on the premium you pay for the insurance policy. You can get a maximum deduction of ₹25,000 if you bought a policy that covers you, your spouse, and your children.

Inclusions: What is Covered

Benefits covered by a mediclaim may vary depending on the insurance company. These are the common benefits covered by mediclaim policies:

Hospital expenses

Expenses incurred due to hospitalization like medicines, oxygen, blood, OT charges, medical tests and diagnosis, chemotherapy, radiotherapy, organ transplantation, etc.

Hospital accommodation expenses

Expenditures toward ICUs are either addressed through the cashless hospitalization feature or are reimbursed by the company.

Day-care hospitalization

Expenditures toward tech-driven medical treatments that do not involve 24-hour hospitalization.

Charges for medical experts

The fees for medical professionals involved during hospitalization like doctors, nurses, etc. are also provided by mediclaim policies.

Hospital lodging expenses

Expenditures towards ICUs are both addressed via the cashless hospitalization feature or are reimbursed via the insurer

Pre and post-hospitalization expenses

Expenses are incurred for up to 30-60 days before and till 60-120 days after hospitalization. It may also include medical assistance for emergency services like ambulance, etc.

Inclusions: What is Not Covered

  • War or any act of war, invasion, an act of a foreign enemy, warlike operations
  • Self-inflicted injuries
  • Biological/Chemical/Radioactive
    /Nuclear fallout
  • Maternity and pregnancy treatments
  • Breach of law/criminal activity
  • Participation in military operations
  • Participation in extreme sports
  • Substance Abuse/Alcohol/Narcotics
  • Treatment of Obesity
  • Cosmetic Surgery
  • Dental Treatment
  • Infertility treatments

Factors that Determine Health Insurance Premium Online

Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses.

No of the Members Included in the floater policy affect the premium

Previous medical history and lifestyle factors are major factors that determine the premium. If no prior medical history exists, the premium will automatically be lower.

Claim-free years can also be a factor in determining the cost of the premium as it might benefit you with a certain percentage of discount which will reduce your premium.

Claims Process

In mediclaim, you can make two types of claims- Cashless and Reimbursement

Cashless Claim

In this type of health insurance claim, the insurer settles all the hospitalization bills with the hospital directly, provided he is hospitalized at a network hospital. The procedure to avail cashless claim for a health insurance policy is:

  • Contact the hospital’s insurance help desk
  • Show the ID card of the insured, provided by the health insurance provider
  • The hospital will verify the insured person’s identity and submit the pre-authorization form to the concerned health insurance provider
  • The insurance provider will review all the submitted documents and process the claim according to the terms and conditions of the health insurance policy.

Some health insurance providers also assign a field doctor to make the hospitalization process easier for the insured.

After the completion of all formalities, the claim is settled as per the terms and conditions of the policy.

Reimbursement of the Claim

In this type of health insurance claim process, the policyholder pays for the hospitalization expenses upfront and requests reimbursement by the insurance provider later. This can be availed at network and non-network hospitals. The insured has to submit the following documents to the insurance provider in order to avail of the claim:

  • Duly filled and signed Claim form
  • Insurance Card or Policy Copy
  • Medical Certificate signed by the doctor
  • Pathological reports like X-ray reports
  • Hospital discharge card
  • Original Bills and receipts
  • Original Pharmacy bills
  • The investigation report, if any
  • FIR / MLC Copy (in case of an accidental claim)
  • NEFT Details to credit Claim Settlement
  • Duly Filled CKYC Form if Claimed amount is above Rs 1L.

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Health Insurance FAQs

Health Insurance is a kind of insurance that covers your medical expenses such as medical bills, hospitalization expenses, etc resulting from any illness/injury. A Health Insurance policy is a contract between an insurer and an individual /group wherein the insurer agrees to provide specified Health Insurance cover at a given "premium". It also provides tax benefits under section 80D of the Income Tax Act, 1961.

There are two types of health insurance policies:

Indemnity Plans: These are traditional health insurance plans that cover your hospitalization expenses up to the sum insured. These plans include individual Mediclaim Insurance, Family Mediclaim, Family Floater Coverage, Senior Citizen Coverage, Unit Linked Health Plans, and top-up/super top-up plans.

Defined Benefit Plan: Under a defined-benefit plan, the insured is compensated as a lump sum amount for the detection of illness. These plans include a Critical Illness Plan, Personal Accident Plan, and Hospitalisation cash benefit plan.

Family Floater is one single policy that takes care of the hospitalization expenses of your entire family. The policy has one single sum insured, which can be utilized by any/all insured persons in any proportion or amount subject to the maximum of the overall limit of the policy sum insured. Quite often Family floater plans are better than buying separate individual policies. Family Floater plans to take care of all the medical expenses during sudden illness, surgeries, and accidents. Dependents are normally covered only up to a particular age limit or when unmarried.

Riders are additional covers that can be added to your health insurance policy. Some of the common riders are as follows:

Critical Illness rider: These cover critical ailments such as cancer, heart attack, paralysis, etc. for which medical expenses are otherwise very high to be covered under a regular health policy. Generally, a lump sum is paid to the insured under a critical illness rider.

Hospital Cash: Compensatory cash provided by the Insurer on a daily basis in case of loss of income and to meet petty expenses

Top-Ups: An additional cover over and above the basic cover and will operate once the thresh hold level is achieved which can be selected in accordance with the basic cover.

Attendant Allowance: Some insurers are giving attendant allowance on a daily basis to accompany the person who is being hospitalized.

Co-Payment: It is a portion of the claim that the policyholder agrees to bear himself in the event of a claim.

Deductible: Also termed excess, it is the portion of the claim that the policyholder has to compulsorily pay first before the insurance company steps in and pays the remaining amount of the claim.

This is the sum insured by the policy you take which should be calculated keeping your existing lifestyle, medical history, income, city of residence, and age in mind.

It is a medical condition/disease that existed before obtaining the Health Insurance policy. Insurance companies usually do not cover such pre-existing conditions, till the first 4 years of continuous insurance cover.

1, 2, or 3 years. Opting for two years or more makes you eligible for discounts.

Certain Health Insurance policies pay for specified expenses towards general health check-ups once in a few years. In most cases, this is available once in four years.

Pre-existing diseases (read the policy to understand what a pre-existing disease is defined as) are excluded under a Health Insurance policy.

Further, the policy would generally exclude certain diseases from the first year of coverage and also impose a waiting period.

There would also be certain standard exclusions such as the cost of spectacles, contact lenses, and hearing aids not being covered, dental treatment/surgery ( unless requiring hospitalization) not being covered, convalescence, general debility, congenital external defects, venereal disease, and intentional self-injury.

Use of intoxicating drugs/alcohol, AIDS, expenses for diagnosis, x-ray or laboratory tests not consistent with the disease requiring hospitalization;

Treatment relating to pregnancy or childbirth including cesarean section, and newborn child up to 90 days naturopathy treatment.

It is a Card that comes along with the health insurance policy which allows you to avail cashless hospitalization normally issued by your Third Party Administrator.

Third-Party Administrators (TPAs) are IRDA licensed entities who serve as intermediaries between the insurer and the insured to ensure smooth settlement of claims. Find the list of TPAs here.

Insurance companies through their TPA’s or inhouse arrangements have tie-up with several hospitals all over the country as part of their network. A cashless facility, allows a policyholder to take treatment in any of the network hospitals without having to pay the hospital bills as the payment is made to the hospital directly by the Insurer/TPA, on behalf of the insurance company. However, expenses beyond the limits or sub-limits allowed by the insurance policy or expenses not covered under the policy have to be settled by you directly with the hospital. A cashless facility, however, is not available if you take treatment in a hospital that is not in the network.

Yes, you can within the free look period, which is generally 15 days after buying a policy. You will get a refund after deducting the pre-acceptance medical screening and underwriting expenses.

Any number of claims is allowed during the policy period unless there is a specific cap prescribed in any policy. However, the sum insured is the maximum limit under the policy.

Yes. When you get a new policy, generally, there will be a 30-day waiting period starting from the policy inception date, during which period any hospitalization charges will not be payable by the insurance companies. However, this is not applicable to any emergency hospitalization occurring due to an accident. This waiting period will not be applicable for subsequent policies under renewal in continuation.

Age is a major factor that determines the premium, the older you are the premium cost will be higher because you are more prone to illnesses.

Previous medical history is another major factor that determines the premium. If no prior medical history exists, the premium will automatically be lower.

Claim-free years can also be a factor in determining the cost of the premium as it might benefit you with a certain percentage of the discount. This will automatically help you reduce your premium.

Family size in the case of floater policies will accordingly affect the amount of premium.

Sum Insured (individual or floater) is the biggest determinant for deciding the premium.

The following documents are generally required for purchasing a health insurance policy:

A duly filled and signed proposal form with a declaration of health wherein the insured may even need to undergo a medical checkup;

Legal identity documents

Health Insurance comes with attractive tax benefits as an added incentive. Section 80D of the Income Tax Act provides tax benefits for Health Insurance. Currently, any person who has purchased a Health Insurance policy by any payment mode other than cash can avail of an annual deduction of Rs. 25000 from their taxable income for the payment of Health Insurance premiums for self, spouse, and dependent children.

If an Individual purchases Health Insurance for parents, then he can avail of an annual deduction of Rs. 25000/- from his/her taxable income. Further additional annual deduction of Rs. 5000/- can be availed if the parents are senior citizen i.e. Age of Parents is above the age of 60 years at the time of policy the purchase. This is in addition to the exemption toward expenses incurred on preventive health check-ups.