Health Insurance

What is Health Insurance?

Health insurance is a financial arrangement in which an insurer agrees to cover the policyholder's medical expenses in exchange for a premium. It ensures financial security during illnesses, accidents, surgeries, or medical emergencies.

Health insurance policies support treatment costs across hospitals, clinics, outpatient departments, and diagnostic centres. Besides emergency care, many policies include preventive health benefits to improve long-term wellness.

With healthcare costs in India rising consistently and modern treatments becoming increasingly expensive, health insurance helps you access advanced healthcare without financial stress. It aligns with both short- and long-term financial goals by reducing tax liabilities and ensuring long-term financial security.

Types of Health Insurance Plans in India

The following are some types of health insurance policies, depending on their specific functions and needs:

What is the difference between Health Insurance and Mediclaim Policy?

When choosing between health insurance and mediclaim insurance, there are many key factors to consider and assess to ensure getting the best coverage for you and your family’s medical and financial security. Here is a table showcasing the difference between the two for further clarity:

While often used interchangeably in certain circles, the difference between health insurance and mediclaim insurance is apparent in its scope of coverage, coverage limits, premiums, additional benefits, claim process, and overall usage. While both the best health insurance policy and mediclaim insurance in India offer financial protection against various medical expenses, medical insurance provides a more substantive coverage for those who need it.

Why Do You Need Health Insurance?

While there are several benefits of availing health insurance, there is a need to consider why a medical insurance policy is essential for most individuals and families:

Unpredictable Medical Costs

Diseases, accidents, and health emergencies can strike at any time. Having medical insurance ensures you get timely treatment without worrying about the potential financial burden.

Medical Inflation

Healthcare in India and across the globe has become costlier every year due to rising costs, advanced treatments, medical tourism, an increase in chronic illnesses, a shortage of medical personnel, and the desire for quality healthcare. This resulted in a medical inflation rate of 14% for India in 2024, the highest rate among Asian countries. A surgery that costs ₹2 lakh today may cost ₹4–5 lakh in a decade. This is where purchasing health insurance early in life, before you need it, protects you from these rising costs.

Financial Stability

Large hospital bills can drain your savings, disrupt financial planning, or push families into debt. This is where investing in a reliable health insurance plan helps protect your short- and long-term goals.

Access to Better Healthcare

Medical insurance enables you to get treated at reputed hospitals without having to worry about medical expenses.

Peace of Mind

Having health insurance as a financial guarantor and knowing you are protected gives you the confidence to live freely, go limitless, and pursue your goals without fear of the unknown.

Family Protection

A family floater plan safeguards you and your loved ones under a single best medical insurance policy, making it convenient while also providing customised, specialised coverage tailored to your family’s unique needs.

Tax Savings

In India, health insurance premiums are tax-deductible; thus, availing them provides a reduction in tax liability under Section 80D of the Income Tax Act, giving you financial benefits under Indian tax laws.

Thus, it is essential to keep in mind that health insurance is not an expense; it is an investment in your and your loved ones’ future well-being.

Choosing the Right Health Insurance Policy in India

When looking for the right health insurance to protect yourself and your loved ones, it is critical to match your needs with available coverage, consider add-ons, compare premiums, and prioritise your needs. Here are some things to consider when choosing the best medical insurance policy in India:

A well-chosen policy ensures long-term health and financial security; therefore, it is crucial to research and purchase the right health insurance for yourself and your loved ones.

Why Should You Compare Health Insurance Plans Online?

When investing in a product such as health insurance, which provides long-term coverage, it is valuable to carefully compare and choose the right policy for financial security and peace of mind. Unlike when you might feel rushed asking another person questions or spending too much time manually computing differences, online comparison can make it much easier and more comfortable for most insurance seekers. Here are some of the key ways online comparison for insurance plans is better:

• Compare premiums

• Check features

• Analyse sum insured options

• Review exclusions and waiting periods

• Check the network hospital lists

• Understand claim settlement processes

• Assess customer ratings

• Make informed decisions without agents

• Purchase instantly

All in one spot instead of having to call intermediaries, online tools simplify research and help you choose efficiently.

Things to Consider Before Buying a Health Insurance Plan in India

When purchasing health insurance for yourself and your loved ones, keep in mind the following aspects for the best idea of what you need and what you are buying:

• Health history of all of the insured

• Family structure

• Age of family members

• Sum insured amount

• Coverage inclusions

• Exclusions

• Co-payments

• Sub-limits on treatments

• Network hospitals

• Waiting periods

• Premium affordability

• Long-term renewability

• Add-on benefits

Carefully evaluating the policy is critical when choosing a policy that truly supports you in times of need. Use the factors above to get the best health insurance plan for yourself and your family.

Factors Influencing Health Insurance Premiums

Health insurance premiums are not static costs. As insurance is a risk-pooling mechanism, it considers each member's risk and determines the actual cost accordingly. 

For example, a smoker and a non-smoker with other conditions remaining the same will be different. Similarly, a person in their 40s will pay a higher premium than someone in their early 20s. 

This is because the risk associated with the older person will be higher, all else equal. The following are some of the factors that influence health insurance premiums:

• Age

• Sum insured

• Type of plan

• Number of members

• Pre-existing conditions

• Lifestyle factors

• City of residence

• Add-ons opted

• Coverage level

• Medical inflation adjustments

These factors are used in actuarial calculations to set premiums that balance risk and long-term sustainability.

Health Insurance Premium Calculator - Include a widget to calculate insurance premiums

Save Tax with a Medical Insurance Policy

Under Section 80D of the Income Tax Act, 1961, if you invest in health insurance, you can get a deduction of up to:

• Self and Family: Up to ₹25,000 per year.

• Senior Citizens (60 years or more): Up to ₹50,000 per year.

• Parents: Additional deduction of ₹25,000.

• Parents (Senior Citizens - 60 years and above): Additional deduction of ₹50,000.

• Preventive Health Check-up: Up to ₹5,000.

This reduces your overall tax liability and supports preventive financial planning.

Why Choose Niva Bupa for Health Insurance?

Niva Bupa is a leading standalone health insurance provider in India with a network of 10,000+ cashless hospitals across the country. When you choose Niva Bupa, you are joining a growing community of over 2 crore+ satisfied customers who trust the brand to protect their and their family’s health and financial well-being. This trust is backed by features that are thoughtfully designed to support real-life needs.

So whether you live in a metro, a tier-2 city, or a small town, you have access to quality hospitals that offer cashless treatment. Niva Bupa’s quick claim approvals, sometimes within 30 minutes, allow you to focus on recovery, not paperwork. With a streamlined, digital-first system, the company ensures your medical care is not delayed by administrative issues.

Another standout feature is lifetime renewability, a promise that your protection continues no matter your age. This gives you long-term security, something vital as medical expenses typically rise with age.

Plans are flexible, with options for individuals, families, senior citizens, newly married couples, and people with specific healthcare needs. Whether you need maternity benefits, critical illness cover, top-ups, or wellness features, you can build a plan that matches your evolving life stage.

With its customer-first approach, transparent processes, and diverse plan portfolio, Niva Bupa is a reliable partner for health insurance planning and long-term financial protection.

Fixed Benefits with Niva Bupa Medical Insurance

When purchasing a medical insurance policy from Niva Bupa, there are certain fixed benefits regardless of plans to consider:

• Cashless treatments at 10,000+ network hospitals

• Coverage for both planned and emergency hospitalisations for reimbursement and cashless treatment

• Pre- and post-hospitalisation care

• Daycare treatment coverage

• No-claim Bonus

• Restoration of sum insured (on select plans)

• Wellness rewards for healthy habits (on select plans)

• Maternity and newborn coverage (on select plans)

• Diagnostic and OPD benefits (where included)

• High sum insured flexibility

• Quick approvals and easy documentation

These fixed benefits help policyholders manage both planned and unexpected medical expenses without worrying about the financial implications.

Understand Eligibility for Health Insurance

Eligibility criteria vary depending on the chosen plan. However, generally, the requirements are:

• Age

  • Adults aged 18–65.

  • Children can be covered from 16 days of age.

  • Senior citizen plans have upper age limits of up to 70 years.

• Medical Tests

  • Mandatory medical tests for those over 45 

  • Others may require routine blood, urine, and organ function tests, depending on pre-existing ailments

• Medical Condition

  • Disclosure of pre-existing conditions is essential; it may lead to waiting periods or influence premiums.

Always check specific policy terms and ensure you meet the eligibility criteria specified above to avail the benefits of a medical insurance policy.

How to Buy a Health Insurance Policy Online?

Buying online is simple:

1. Visit the Niva Bupa website.

2. Enter your Phone Number, Name, and Date of Birth.

3. Click on next to select the plan type between Individual (Separate sum insured for each individual) and Family (Aggregate sum insured for each member).

4. If you select Individual, you will need to enter the number of adult members to be covered, their date of birth, and the number of child members under 30. 

5. If you select Family, you will need to enter “How many Adult Members to be covered?”, choose the number of Child Members, enter the Date of Birth of the eldest member, and provide your Email ID for correspondence and to receive the policy document.

6. Your premium will be calculated, and you can select the policy's coverage level based on the information provided and your specific needs. 

7. Select any add-ons, if required, including the level of coverage, and select the members who apply to them.

8. You can then preview the cost and check the breakdown. Once done, click “Pay Now” to purchase the policy, selecting a policy duration of 1-5 years. 

9. Once on the payment gateway, you can choose Credit/Debit Card, NetBanking, EMI on Cards, Cardless EMI, UPI, Wallets, or Loan Marketplace to make the payment.

10. Receive policy documents digitally via email.

By following this walkthrough, you can easily secure the right health insurance for yourself and your family.

How Do Health Insurance Claims Work?

A health insurance claim is the process of requesting the insurer to pay for medical expenses covered under your policy. Claims can be cashless or reimbursement-based.

1. Cashless Claims

Cashless claims are available at network hospitals. When you are admitted, the hospital and insurer coordinate through pre-authorisation. Once approved, your treatment proceeds without you paying the major expenses upfront. After treatment, the insurer settles the bills directly with the hospital.

2. Reimbursement Claims

If you receive treatment at a non-network hospital, you can file a reimbursement claim. You must initially pay the hospital bills. Once discharged, submit all documents, bills, and reports to the insurer. After review, the insurer reimburses the admissible amount.

The process involves simple steps, intimation, documentation, verification, approval, and settlement. Niva Bupa’s digital-first approach speeds up the process and makes it more convenient.

Health Insurance Claims

Every insurer has a standard claim process. Key steps include:

• Notify the insurer

• Choose cashless or reimbursement

• Submit required documents

• Pre-authorisation for planned admissions

• Verification

• Settlement

Niva Bupa simplifies claims with digital submission, tracking, and faster turnaround times.

Documents for Health Insurance Claim Reimbursement

You may need:

• Claim form

• Hospital bills

• Discharge summary

• Test reports

• Doctor’s prescriptions

• Diagnostic bills

• Pharmacy bills

• Accident reports (if applicable)

• ID proof

Proper documentation expedites reimbursement.

Who are Third-Party Administrators in Health Insurance?

When it comes to purchasing a medical insurance policy, third-party administrators (TPAs) hold significant influence over your experience. They are the crucial individuals and agencies you'll directly interact with when making claims. So, if you're planning to secure a health insurance policy soon, a TPA will play a vital role in your journey.

TPA

A third-party administrator, or the TPA, is not an employee of any health insurance company but an independent and separate entity that acts as the intermediary between you and your insurance provider. The TPA is licensed by the IRDAI to execute this task for insurers across categories, and not just for players engaged in health insurance. 

It can be an individual, an agency, or a company retained by the insurer to perform various administrative services, such as managing customer service on the insurer's behalf. Typically, it receives a 5.5% fee of the premium amount. However, for the customer, the services provided by the third-party administrator are free, with no hidden costs in the contract.

Scope Of Work for a TPA

The scope of work for a TPA is primarily customer service. This includes claims processing, which requires you to interact with a TPA. Insurers across verticals, including health insurance companies, outsource their claims processes (in part or in full) to a TPA of their choice. 

In the case of medical insurance-related claims, however, the third-party administrator also coordinates with the network hospital or any other hospital where the policyholder received treatment before filing the claim. 

In India, many health insurance companies have their own dedicated departments for claims processing. For instance, Niva Bupa Health Insurance processes your claims without a TPA, significantly reducing the time required.

Role/Importance Of TPA

While some of the functions of the third-party administrator have been touched on earlier, let's delve into further details for better insight. Broadly, the TPA is supposed to promote cashless facilities, provide customer service, and process claims.

Customer Service

The work of the third-party administrator with regard to you begins the day the policy is sold to you, i.e. when you enter your medical insurance provider’s database. Any service of yours which is due is now the responsibility of the TPA. Some of these services include delivery of the health/identity card, addressing your grievances, and, of course, settling claims. 

The TPA streamlines costs and services, keeps you posted on network hospitals, and addresses any concerns you may have. The TPA also makes payments to the hospital (in non-cashless cases) and assists with reimbursement through your provider.

Cashless Service

The TPA is also responsible for building the health insurance company's hospital network. In the process, it provides you, the insured, with a cashless facility. It takes the call on the empanelment of a hospital based on its service track record, infrastructure and facilities, management background, and IT infrastructure.

Claims Processing

This is the role for which the TPA is best known. It coordinates with hospitals for claim settlements, verifies bills for treatments, checks for false claims, and even settles payments with hospitals for cashless facilities.

IRDAI Amendments

Until recently, a policyholder had to accept any third-party administrator their health insurance provider chose. This changed on December 3, 2019, when the IRDAI announced amended regulations giving customers the right to choose a TPA from the list suggested by their health insurance provider. 

To be precise, “The policyholder can choose a TPA of their choice from amongst the TPAs engaged by the insurer,” as stated in the notification on the website. Keep in mind, though, that as a policyholder, you can only choose the TPA from the list available at the time you buy or renew the policy. 

If you do not choose any of the suggested TPAs, the health insurance company can assign you a TPA of its choice. IRDAI also allows health insurance companies to limit the TPA list based on the health insurance product and the policyholder's geographical location. 

Hence, if the insurer engages the services of only one TPA because of those factors, you will have no option but to go along with that particular TPA. The regulator also says it is the insurer’s “prerogative” to engage or discontinue a TPA's services for a specific health insurance product. Also, the only time you can choose (an alternate) TPA is if the services of the original TPA are terminated during the period of your health insurance coverage.

Knowing all About Inclusions & Exclusions

Inclusions typically include:

• Hospitalisation

• Surgeries

• ICU charges

• Diagnostics

• Ambulance costs

• Daycare procedures

• Pre- and post-hospitalisation

• Certain modern treatments

• Maternity (if applicable)

• AYUSH coverage (where applicable)

Exclusions may include:

• Cosmetic procedures

• Non-prescribed treatments

• Self-inflicted injuries

• Experimental treatments

• Waiting period for specific illnesses

Understanding inclusions and exclusions ensures there are no surprises during claims.

Health Insurance Myths

Myth 1: Young and Healthy People Don’t Need Health Insurance

That is untrue, as medical emergencies can occur to anyone at any age, regardless of health or lifestyle. From genetic illnesses to environmental factors, there are many reasons one may need health insurance. So, no, age and current health conditions have little to do with whether health insurance is required.

Myth 2: Employer-Provided Health Insurance is Always Sufficient

This is untrue, as what employers provide under health insurance is designed for dozens or hundreds of employees and may not meet the unique needs of all individuals. Whether it is limited coverage in terms of risks or the sum insured, it is necessary to have at least one supplementary health insurance policy to lock in insurance prices when younger, ensure lifetime renewability, or maintain coverage even after leaving a previous employer.

Myth 3: Health Insurance is Too Expensive

This depends on some very specific circumstances. As insurance is a risk-based business in which money is pooled from thousands of customers, the premium charged to each customer is not the same. 

Whether it is the type of policy, comprehensiveness of the policy, age, predisposition to certain illnesses, medical history, pre-existing diseases, smoker/non-smoker, drinker/non-drinker, obese/not obese, or medical inflation rate, all of these factors are considered, and a specific premium is determined for each customer. 

Based on these factors, the customer may be charged a very low or very high premium, requiring a nuanced understanding of the policy to determine its value.

Myth 4: You Don’t Need Health Insurance if You Have Savings

That is untrue; savings at the end of the day are limited, and with medical inflation on the rise, the value of saved money depreciates with inflation, resulting in higher spending over time and saved assets reducing in value at a disproportionate rate. 

Thus, always look for specialised solutions, such as medical insurance, especially early in life, for comprehensive coverage at a lower cost than paying 5 or 6 times that amount in insurance and dozens of times that in medical expenses.  

Myth 5: Health Insurance Covers Everything

No, while health insurance covers a wide range of medical risks, it offers financial security and peace of mind over time. It does not cover everything and has a specific list of permanent and plan-specific exclusions that need to be checked and verified before applying, to ensure you are covered for any potential risks you may face.

Myth 6: Pre-existing conditions aren’t covered

That is untrue. While pre-existing conditions often have a waiting period of 1 to 4 years, depending on the policy and insurer, they are covered if they are listed in the policy opted for and disclosed at the time of purchase.

Myth 7: The Best Plan is the One with the Lowest Premium

This is untrue. One should never opt for the lowest premium as the primary criterion, as that may lead to incomplete coverage, whether in terms of risks or sum-insured, higher co-pays, sub-limits for particular procedures, limited network hospital coverage, longer waiting periods, etc. If, however, you consider all the necessary aspects, including the insurer's reliability, and the premium is still lower, you can consider getting the one with the lower premium. 

Myth 8: Insurance companies cover all expenses in the event of hospitalisation

That is untrue; claim settlement typically depends on the terms and conditions of the specific policy chosen, as well as the sum insured. For example, while you may purchase a policy with a sum insured of ₹10 Lakhs, and claim settlement for expenses of ₹3 Lakhs, the final payout could be lower than ₹3 Lakhs even if the sum insured is not exhausted due to sub-limits, room rent capping, higher cost of treatment, co-payment clause, excluded expenses, etc., depending on the specific policy opted for. 

Myth 9:  You get coverage as soon as you buy the plan

This is untrue as the coverage for different aspects of the policy depends on the specific waiting period assigned to it. While most coverages can be claimed after a 30-day waiting period from policy issuance, some specific coverages, such as pre-existing diseases, maternity, and critical illness, may require a waiting period of 1 to 4 years, depending on the policy opted for.

Myth 10: Pregnancy is not included in health insurance

That is untrue, as some health insurance policies offer coverage for delivery and labour expenses, newborn baby care, pre- and post-hospitalisation natal care, ambulance cover, and more. So, check the specific policy you need based on your family's plans in the near future, especially since maternity coverage often comes with a waiting period, so you need to have the policy for a specific duration before being eligible for coverage. 

Myth 11: Hospitalisation is a must to get your claim settled

This is untrue, as leading insurers such as Niva Bupa also offer preventive health check-ups, home care/domiciliary care, and OPD services in some instances, depending on the specific policy chosen.

Myth 12: Online plans are not safe

This is untrue, as most insurance providers today offer medical insurance plans online. This is to improve accessibility, give customers time to do their research and choose what they need at their own pace, and reduce intermediary costs, resulting in cheaper, better, and more secure policies tailored to the individual and their needs. 

Myth 13: Claims are rarely approved

This is untrue, as most insurers these days have claim settlement ratios in the 80%, and leading insurance providers such as Niva Bupa have ratios in the 90%, meaning that over 90% of all claims are approved. Claims are settled to varying degrees depending on the policy terms and conditions. Remaining claims are rejected or put on hold due to missing documents, lapsed policies, unrecognised hospitals, filing claims during the waiting period, false information, concealment of pre-existing diseases, exhaustion of the sum insured, delayed claim filing, etc.

Myth 14: People who smoke and drink are not eligible for health insurance: 

That is untrue; while smokers and drinkers will be required to pay a higher premium than non-smokers and non-drinkers, they will still be eligible for the policy, subject to meeting other criteria depending on the specific policy chosen.

Myth 15: Hiding pre-existing illnesses can help get insurance

No, this is untrue. While it can help obtain insurance for those who don’t need mandatory medical tests, any investigation of a claim that reveals the policyholder knew of the pre-existing condition beforehand will lead to claim rejection and, depending on the situation, further action. 

Myth 16: Network hospitals can only be found in big cities

This is untrue; leading health insurance companies like Niva Bupa have over 10,000 network hospitals across India, covering over 450 Districts, enabling quick, easy cashless claim settlement pan-India. And where network hospitals are not available, you can visit any registered hospital and request reimbursement settlement, which will be completed in the prescribed duration as long as the hospital is not a part of the unrecognised hospital list.

These misconceptions often delay crucial purchase decisions.