How do I read my health insurance policy and find the clause that answers my question?

Read a health policy in a fixed order: the schedule for your own details, the Customer Information Sheet as a map, the definitions, and then the coverage, waiting periods, exclusions and claim conditions in the wording. The wording is the contract — where the Customer Information Sheet says something different, the policy document prevails. A dispute can turn on one defined word or one limit, so find the clause number before you argue about it.

A health policy is not one document but a small bundle, and each question you have is answered in a particular part of it. Reading the parts in the right order saves time and stops you relying on a summary when the detailed clause says something else. This guide gives that order, then a table of where the common questions are answered.

Make sure you have the whole policy

Within 15 days of accepting your proposal, the insurer must give you, free of charge, the policy document, a copy of the proposal form you submitted and the Customer Information Sheet (CIS). If the insurer issued your policy to you electronically, it must also give you a paper copy if you ask.^{[1, 2]}

If any of these is missing, ask the insurer for it in writing before you rely on anything else. Keep the proposal form too: it records what you declared when you applied, which matters if non-disclosure is ever raised.

A reading order that finds answers quickly

1. 1

   Your schedule

   The schedule carries your own facts: who is insured, the sum insured and the policy period. A health policy must also state the date from which you have been continuously covered by any insurer without a break. Check these first — a wrong continuous-cover date can change how your waiting periods are counted.^[1]

2. 2

   The Customer Information Sheet

   The CIS explains the basic features of the policy in simple words in one place, and its format asks the insurer to give the policy clause number against each item, which makes it a useful index. It is a summary, though: in case of any conflict, the policy document prevails.^{[3, 1]}

3. 3

   The definitions

   Words such as hospitalisation, pre-existing disease, sub-limit and co-payment have fixed meanings in the definitions section, and those meanings apply wherever the word appears. When a clause seems to say something surprising, check the definitions of the words it uses.^[4]

4. 4

   Coverage and limits

   The benefits section says what is paid. The limits must be stated too: sub-limits, any proportionate deductions and package rates, with a cross-reference to the section that applies them, as well as any co-pay and deductible.^[1]

5. 5

   Waiting periods

   The pre-existing disease waiting period and any specific waiting periods must be stated in the policy. Read them against the continuous-cover date in your schedule. What a waiting period means explains the different kinds.^[1]

6. 6

   Exclusions

   Every exclusion that applies must be written into the policy document, and no deduction can be made from a claim in the name of an exclusion that is not there. Read the exclusion's exact words and check whether it really names the cause of your claim.^[1]

7. 7

   Claim procedure and conditions

   The documents needed for a claim, and the procedure to follow, must be listed in the policy document and on the insurer's website. The conditions also set out what you must do when you claim — see what the conditions section expects of you.^{[2, 1]}

Where each common question is answered

Mistakes that lead people astray

• Reading the brochure instead of the wording: Sales material is not the contract. Which document counts explains the difference.
• Reading this year's wording for last year's claim: A health policy must warn that its terms and premium rate could change on renewal, so use the wording for the policy year in which the treatment happened.^[1]
• Skipping the endorsements: A change made after the policy was issued — a new member, a corrected date — is recorded in an endorsement. One insurer's wording, for example, defines 'Policy' to include the schedule and any applicable endorsements.^[4]
• Reading a clause without its definition: A word like 'hospitalisation' can carry conditions that the clause itself does not repeat. In one insurer's wording, it means admission for at least 24 consecutive hours of in-patient care, except for specified procedures.^[4]

Once you know which clause the insurer relied on, you can compare it with your own facts. If a health claim has already been rejected or cut, the letter must refer to the specific terms and conditions used, so start with those clause numbers.^[3]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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