How to read your health insurance policy: four documents and ten clauses

What documents make up a health insurance policy?

Your policy is four documents read together: the policy schedule, the Customer Information Sheet (CIS), the policy wording and any endorsements. IRDAI’s 2024 policyholder-protection rules also require the insurer to send a copy of your proposal form, so you can see exactly what you declared.

If the proposal form misses a condition you had, raise it with the insurer in writing now rather than at claim time. Our page on pre-existing diseases explains what has to be disclosed and why.

Which document wins if they disagree?

The policy document wins. IRDAI’s standard CIS format ends with a note that if there is any conflict, the terms and conditions in the policy document prevail. Treat the CIS as a map and the wording as the rulebook.

Also check that the wording you are reading is the one that applies to you. Every product has a Unique Identification Number (UIN) printed on the schedule. Insurers revise wordings, so a PDF downloaded from a website may be a newer or older version. Match the UIN before you rely on it.

How to read the Customer Information Sheet

Read the CIS first, because it puts the clauses that cost you money on one or two pages. IRDAI’s 2024 Master Circular on health insurance makes it mandatory with every policy and sets its format. It must be in at least 11-point font and is available in a regional language on request. Each item has a column pointing to the clause number in the wording.

• Items 3 and 4: whether the policy pays actual bills (indemnity) or a fixed amount (benefit), and whether the sum insured is individual or a family floater.
• Items 5 and 6: what is covered, and a summary of what isn’t.
• Item 7: waiting periods.
• Item 8: financial limits: sub-limits, room or ICU limits, co-payment and any deductible “per claim / per year”.
• Items 9 to 11: the claims process, turnaround times and grievance contacts, including the Insurance Ombudsman.
• Item 12: free look, renewal, migration and portability, changing the sum insured, and the moratorium period.
• Item 13: your obligations, starting with disclosing pre-existing conditions.

The waiting-period block (item 7)

The standard format reads like this, with your policy’s numbers in place of the blanks:

Initial waiting period: xx days for all illnesses (not applicable in case of continuous renewal or accidents). Specific waiting periods: xx months for xx diseases/procedures. Pre-existing diseases: covered after xx months.

Example. Your CIS shows 30 days, 24 months for cataract and hernia, and 36 months for pre-existing diseases. Your policy started on 1 February 2025. A new illness is covered after the first 30 days, from early March 2025. Cataract surgery is covered from 1 February 2027, and a declared diabetes condition from 1 February 2028, as long as you renew without a break. Accidents are covered from day one. Our guide to health insurance waiting periods covers each type in detail.

How a policy wording is organised

Most wordings follow a similar order, partly because IRDAI standardised many definitions and exclusions in 2019–2020 and insurers still use that layout. Once you know the order, you can jump straight to the section you need.

1. Preamble or operative clause: the basic promise to pay for covered treatment, subject to the terms.
2. Definitions: standard terms such as “hospital”, “in-patient care” and “pre-existing disease”, plus product-specific ones such as room rent and “associated medical expenses”.
3. Benefits or coverage: in-patient treatment, pre- and post-hospitalisation, day care, domiciliary, AYUSH, modern treatments, ambulance and optional covers. Limits are often written next to each benefit.
4. Waiting periods and exclusions: many wordings still use the 2019–2020 codes, such as Excl01 (pre-existing diseases), Excl02 (specified disease or procedure waiting period) and Excl03 (30-day waiting period), through to Excl18 (maternity), followed by any product-specific exclusions.
5. General terms and clauses: disclosure, renewal, grace period, cancellation, free look, migration, portability, moratorium and multiple policies.
6. Claims procedure: how and when to intimate a claim, documents, cashless and reimbursement rules, and settlement timelines.
7. Grievance redressal: the insurer’s grievance officer, IRDAI’s Bima Bharosa portal and the Insurance Ombudsman.
8. Annexures: lists of non-payable items, day-care procedures, sub-limit tables and Ombudsman office addresses.

The ten clauses to read first

These ten clauses decide most of what you pay at claim time. Each links to a full explanation.

1. Room rent limit. Look in the schedule and the in-patient benefit for a daily amount, a percentage of sum insured or a room category.
2. Proportionate deduction. Search for “associated medical expenses”. It decides how much of the bill is cut if you take a costlier room.
3. Co-payment. A percentage of each claim you pay yourself. Check for age-linked, zone-linked or non-network co-pays.
4. Sub-limits. Caps on particular treatments, such as cataract, or on items such as ambulance charges. Usually in the benefits table or an annexure.
5. Non-payable items. The annexure listing items the policy won’t pay, such as many consumables.
6. Pre-existing disease. The definition and its waiting period, often under Excl01.
7. Moratorium period. After 60 continuous months, IRDAI rules say a claim can’t be contested for non-disclosure except for established fraud.
8. Waiting periods. The initial waiting period and the list of specified diseases, often under Excl02 and Excl03.
9. Restoration benefit. Whether your sum insured is refilled after a claim, and for which later claims.
10. No-claim bonus. How much cover is added for a claim-free year, and what happens to it after a claim.

Example: how four clauses combine on one claim

Example. Your policy started 30 months ago and has a 24-month waiting period for cataract, a cataract sub-limit of ₹40,000 per eye, a 10% co-payment and a list of non-payable items in an annexure. The hospital bill for one eye is ₹70,000, including ₹2,000 of non-payable items.

This example applies the co-pay to the amount left after the sub-limit, in line with IRDAI’s CIS definition of co-payment as a share of the admissible claim amount. Your wording’s claims or co-payment clause sets the actual order, and the order can change the result. If the claim had come in month 20, the waiting period clause alone would have meant the insurer paid nothing.

What is the free-look period in health insurance?

The free-look period is 30 days from the date you receive the policy document. It applies to new individual health policies with a term of one year or more, and lets you cancel if you aren’t happy with the terms, whatever your reason. It was 15 days before IRDAI’s 2024 rules.

Under IRDAI’s 2024 policyholder-protection regulations, the refund is due only if you haven’t made a claim, and it must be paid within 7 days of your request. It can be reduced only by a proportionate risk premium for the days you were covered, any medical examination costs the insurer paid and stamp duty. The free look is for new policies, not renewals. The rules before 2024 also excluded ported policies, so check what your wording says before you rely on it after porting. Use the first 30 days to read the wording and check your proposal form.

What to check in your policy

1. Policy schedule: the UIN, names and ages of insured members, “Sum Insured”, “Floater”, “Room Rent”, “Co-payment”, “Deductible” and any special condition against a member.
2. Customer Information Sheet: items 7 and 8, and the clause number beside each, so you can jump to the wording.
3. Policy wording: search the PDF for “Excl01”, “Excl02”, “Excl03”, “Pre-Existing Disease”, “Moratorium”, “Associated Medical Expenses”, “Sub-limit” and “Cumulative Bonus”.
4. Annexures: search for “Annexure”, “List I” and “non-medical” to find the non-payable items list.
5. Endorsements: search your email for “endorsement” and check each one against the schedule.
6. Proposal form copy: every health question you answered, for every member.

Where people get caught out

• Reading only the brochure or the CIS. Both are summaries. The wording decides the claim.
• Reading the wrong version. A wording with a different UIN may have different limits.
• Missing a member-specific condition. A co-pay or exclusion can be written against one person in the schedule, not in the wording.
• Not checking the proposal form. A condition missed by an agent filling the form can still be treated as non-disclosure.
• Reading the policy only at claim time. The 30-day free look is the time to spot a room rent limit, co-pay or exclusion you didn’t expect, while you can still cancel without giving a reason.