Health insurance terms, explained in plain English

How to use this page: jump to the group you need — Policy basics · The people on a policy · Types of health cover · Cost & cost-sharing · Waiting periods · What's covered · What's excluded · Claims vocabulary · Buying & underwriting · Renewal & portability · Regulator, tax & grievance · Ratios you'll see — or read straight through.

A note on how we've defined things. Where a number is set by the regulator (a waiting-period cap, a claim timeline), we state it directly and cite the rule. Where a number depends on the insurer or the plan, we tell you it varies and what to check. We never guess.

Policy basics

The building blocks that appear on every health policy.

Health insurance

a contract where you pay a yearly premium and the insurer pays your covered hospital bills, up to an agreed limit. In India it's regulated by the IRDAI and is usually an annual, renewable policy.

Mediclaim

an older, everyday word for a basic hospitalisation health insurance policy. People use it loosely to mean any health cover, but technically it refers to plans that reimburse in-patient medical expenses.

Sum insured

the maximum amount the insurer will pay in a policy year. If your sum insured is ₹10,00,000, that's the ceiling on what you can claim across the year. Choose it against today's hospital costs in your city, not yesterday's.

Premium

the amount you pay for the cover, usually once a year. It's set by your age, the sum insured, the plan, your city (see zone-based pricing), and your health disclosures.

Policy term / tenure

how long the contract runs before renewal, usually one year. Some insurers offer 2- or 3-year policies at a discount.

Base cover

your main hospitalisation policy, before any add-ons. Riders and top-ups sit on top of the base.

Rider / add-on

an optional benefit you bolt onto the base policy for an extra premium — for example, a maternity add-on, a consumables cover, or an OPD add-on.

Policy document / policy wording

the full legal contract. The two pages worth reading before anything else are the schedule (your specific sum insured, waiting periods and limits) and the exclusions.

Policy schedule

the personalised summary page listing your sum insured, premium, covered members, waiting periods and any sub-limits. This is your policy at a glance.

Endorsement

an official change to a live policy — adding a newborn, correcting a name, updating a nominee. It's issued as a document that amends the original schedule.

The people on a policy

Proposer / policyholder

the person who buys the policy and pays the premium. On a family plan, the proposer may or may not be one of the people covered.

Insured member

anyone whose medical bills the policy will pay: you, your spouse, children, parents, depending on the plan.

Nominee

the person who receives any payout due after the insured member's death (relevant for benefits like personal-accident cover attached to a health plan). Keep it current — an outdated nominee is one of the most common, most avoidable claim delays.

Dependant

a family member covered under your policy who relies on you — typically spouse, children and parents. Insurers define eligible dependants in the wording.

Types of health cover

Individual policy

one sum insured for one person. If you claim, only your own cover is used — a family member's cover is untouched. Best when one person has higher health risk.

Family floater

one shared sum insured covering the whole family. Cheaper per head, but a single large claim can use up the cover for everyone that year. Best for young, healthy families.

Top-up plan

extra cover that activates only after a deductible (a threshold) is crossed — but the deductible must be met by a single hospitalisation. Cheaper than raising your base sum insured.

Super top-up plan

like a top-up, but the deductible can be met by the total of all your hospitalisations in a year, not just one. This makes it far more useful for families and is usually the better layering choice.

Group / corporate health insurance

cover provided by an employer or association to a group. Convenient and often cheap, but it ends when you leave the job — which is exactly why a personal policy alongside it matters.

Retail / individual health insurance

a policy you buy yourself, directly, that stays with you regardless of employment. The cover that's actually yours.

Standardised products

regulator-defined plans with identical features across all insurers, so you compare only on price and service. The best-known is Arogya Sanjeevani, a simple standard indemnity plan.

Senior citizen health insurance

plans designed for people 60+, often with higher premiums, mandatory co-pay and specific sub-limits. Note: IRDAI removed the maximum entry-age cap in 2024, so insurers can no longer refuse you cover purely for being old.

Critical illness plan

pays a lump sum on diagnosis of a listed serious illness (cancer, heart attack, stroke and so on), regardless of your actual bills. Different from a hospitalisation plan, which pays the bills themselves.

Personal accident cover

pays a lump sum for death or disability caused by an accident. Often sold alongside health cover but is a distinct product.

What it costs — and how costs are shared

This is the group of terms that quietly shrinks claims. Read it twice.

Deductible

the amount you pay yourself before the insurer starts paying. Common in top-up and super top-up plans. A ₹5,00,000 deductible means the plan pays only above that figure.

Aggregate deductible

a deductible met by the total of your year's medical bills (the super top-up model), rather than by a single bill.

Co-payment (co-pay)

a fixed percentage of every claim that you pay, and the insurer pays the rest. A 20% co-pay on a ₹1,00,000 bill means you pay ₹20,000. Common on senior-citizen plans. Why it matters at claim time: co-pay applies to every single claim, for the life of the policy — it's not a one-time cost.

Sub-limit

a cap on how much the insurer pays for a specific item, even if your overall sum insured is far higher. A ₹50,000 sub-limit on cataract surgery means that's all you get for it, regardless of a ₹10,00,000 sum insured.

Room rent limit / room rent capping

a sub-limit on your hospital room charge, often set as a percentage of sum insured or a fixed rupee amount per day. Its danger is proportionate deduction (below). Prefer plans with no room-rent limit.

Proportionate deduction

the trap inside a room-rent limit. If you take a room costing more than your cap, the insurer scales down your entire bill — surgeon's fee, tests, everything — in the same proportion. Choosing a ₹6,000 room on a ₹4,000 cap can cut a large claim by a third.

Disease-wise sub-limit / capping

a per-treatment cap for named procedures (knee replacement, cataract, hernia). Always check these before assuming your full sum insured is available.

Zone-based pricing

insurers price by city tier because metros cost more to treat in. If you buy in a lower-cost zone and get treated in a metro, some plans apply a co-pay — check before you travel for treatment.

Loading

an extra premium the insurer charges because of a health risk disclosed during underwriting. It's a higher price, not a rejection.

GST on premium

individual health insurance premiums are exempt from GST for premiums due on or after 22 September 2025. Group or employer policies may still attract GST. This saving lowers the premium bill; it is not part of your cover.

Waiting periods — the clocks inside your policy

Every health policy has several clocks running. Under the IRDAI's 2024 Master Circular the maximum lengths were shortened — here are the current caps.

Initial waiting period

the first 30 days of a new policy, during which only accident-related hospitalisation is covered. Illness claims don't count until day 31.

Pre-existing disease (PED)

any condition you were diagnosed with, or took treatment/advice for, before buying the policy. You must declare it honestly; non-disclosure is the single most common reason claims get rejected.

Pre-existing disease (PED) waiting period

the time before a declared pre-existing condition is covered. Since April 2024 this is capped at a maximum of 36 months (down from 48). Many plans offer shorter — check yours.

Specific / named illness waiting period

a waiting period (commonly 1–2 years, capped at 36 months) for particular ailments the insurer lists — cataract, hernia, certain joint or ENT procedures.

Maternity waiting period

the time before pregnancy and delivery expenses are covered, typically 9 months to 4 years depending on the plan and add-on.

Moratorium period

after 60 continuous months (5 years) of coverage, the insurer can no longer reject a claim on grounds of non-disclosure or misrepresentation, except for proven fraud. Reduced from 96 months (8 years) in 2024. Ported and migrated years count towards it. Why it matters at claim time: once you cross the moratorium, an old, honestly-forgotten detail can't be used to deny you.

Survival period

in critical-illness plans, the number of days you must survive after diagnosis for the lump sum to be paid (often 15–30 days).

What's covered

The benefits side of the policy.

In-patient hospitalisation

the core cover: expenses when you're admitted for at least 24 hours — room, nursing, surgeon, ICU, medicines, tests.

Day care procedures / treatment

treatments that once needed a long admission but now take under 24 hours thanks to technology (cataract, dialysis, chemotherapy, some scopes). Covered even without a full-day admission.

Pre-hospitalisation expenses

covered medical costs before admission (consultations, diagnostics), typically for 30–60 days prior.

Post-hospitalisation expenses

covered costs after discharge (follow-ups, medicines, tests), typically for 60–90 days.

Domiciliary hospitalisation

treatment taken at home because the patient couldn't be moved or a hospital bed wasn't available, but which would otherwise have needed admission. Covered under conditions set in the wording.

Ambulance cover

reimbursement of ambulance charges to hospital, usually up to a fixed per-event limit.

AYUSH treatment

in-patient treatment under Ayurveda, Yoga, Unani, Siddha and Homeopathy at a recognised facility. Now covered by most plans.

Organ donor expenses

the donor's hospitalisation costs for a covered organ transplant to the insured member.

Restoration / refill / reinstatement benefit

if you exhaust your sum insured in a policy year, the insurer restores it (fully or partly) for further, unrelated claims that year. Read whether it applies to the same illness or only new ones.

No Claim Bonus (NCB) / cumulative bonus

a reward for a claim-free year: your sum insured is increased (commonly 5–50%) at renewal at no extra cost. Some plans reduce it after a claim; others protect it.

Health check-up benefit

a free or subsidised annual preventive check-up, sometimes tied to claim-free renewals.

Maternity / newborn cover

pregnancy, delivery and newborn-baby expenses, available after a waiting period, usually as an add-on.

Hospital cash / daily cash benefit

a fixed daily amount paid for each day of hospitalisation, meant to cover incidentals your indemnity cover doesn't (attendant, travel, lost income).

Consumables cover / "non-medical items"

an add-on covering the long list of gloves, syringes, gowns and administrative items that hospitals bill but base policies often exclude. These "non-payables" can be 5–10% of a bill.

Wellness benefits

discounts, reward points or app-based perks for staying healthy. Nice to have; never the reason to choose a plan.

Second medical opinion

a benefit letting you get an expert's independent view on a serious diagnosis, arranged by the insurer.

What's not covered

Exclusion

anything the policy won't pay for. Every plan has a list; reading it is the fastest way to avoid a rejected claim.

Permanent exclusion

something never covered under the policy, sometimes applied to a specific pre-existing condition the insurer agreed to take on only on that basis.

Standard exclusions

a regulator-defined common list insurers must follow (for example, cosmetic surgery, most self-inflicted injury), so exclusions are comparable across plans.

Non-payable items / non-medical expenses

the itemised consumables and administrative charges hospitals bill that base policies typically don't pay unless you have a consumables add-on.

Co-pay, sub-limits and room-rent caps

technically not exclusions, but they reduce what you get paid. Treat them as "partial exclusions" and check them as carefully as the exclusion list.

Claims vocabulary

The part of insurance that's actually hard — and where a dedicated claim expert earns their place. 25,000+ claims settled and counting, with a 98% claims resolution rate.

Claim

your formal request to be paid for a covered medical expense. Two routes exist: cashless and reimbursement.

Cashless claim / cashless hospitalisation

the insurer settles the hospital directly, so you don't pay the covered amount upfront. Available at network hospitals and, increasingly, everywhere (see Cashless Everywhere).

Cashless Everywhere

an industry framework letting you claim cashless even at non-network hospitals, subject to prior intimation and the insurer's terms — so you're not forced to pay upfront just because a hospital isn't on the list.

Reimbursement claim

you pay the hospital yourself, then submit bills and documents to be paid back. Used at non-network hospitals or when cashless isn't arranged in time.

Pre-authorisation (pre-auth)

the insurer's approval to go cashless, obtained before or at admission. For planned treatment, arrange it in advance; for emergencies, it's requested at admission. Under the 2024 rules, insurers must decide on a cashless request within one hour, and grant final discharge authorisation within three hours of the hospital's request.

Network hospital

a hospital that has a cashless tie-up with your insurer or TPA. Treatment here is smoothest. Check the current list — it changes.

Preferred Provider Network (PPN)

a subset of network hospitals with pre-agreed package rates, sometimes offering better cashless terms.

Non-network hospital

a hospital without a cashless tie-up. You'll usually reimburse — unless Cashless Everywhere applies.

Third Party Administrator (TPA)

the intermediary that processes cashless approvals and claims on the insurer's behalf. Some insurers run claims in-house instead. Why it matters: the TPA, not the hospital, decides your cashless approval — which is why having your own advocate helps.

Claim intimation

telling the insurer a claim is coming: immediately for emergencies, in advance for planned treatment. Missing the intimation window is a needless reason claims stall.

Discharge summary

the hospital's official record of your admission, diagnosis, treatment and discharge. The single most important claim document — a vague one causes queries.

Query / claim query

a request from the insurer for more information or documents before deciding. A prompt, complete reply is the difference between a fast settlement and a stuck one. This is where MITRA does the chasing for you.

Repudiation

the formal word for a rejected claim. A repudiation must come with written reasons, and it can be challenged (see Ombudsman).

Deduction

an amount the insurer removes from your claim — for non-payable items, a sub-limit, a co-pay or proportionate deduction. A "settled" claim can still be paid short; always read the settlement statement.

Claim settlement timeline

under the 2024 rules, insurers must settle (or reject with reasons) a claim within a defined window after receiving the last document, and pay interest for delays beyond it. This is a right, not a favour.

Buying & underwriting

Proposal form

the application where you declare your age, health, habits and history. Everything you sign here is the basis of the contract — fill it yourself, truthfully.

Underwriting

the insurer's assessment of your risk, which decides your premium, any loading, exclusions, or whether they'll cover a condition at all.

Disclosure

telling the insurer the full truth about your health and history. Non-disclosure — leaving something out — is the leading cause of rejected claims, even honest omissions.

Material fact

any information that would affect the insurer's decision to cover you or at what price (a past surgery, a chronic condition, tobacco use). If in doubt, disclose it.

Pre-policy medical check-up (PPC / PPMC)

health tests the insurer may require before issuing cover, more common with age or a disclosed condition. The insurer typically bears most of the cost.

Free-look period

a window after you receive the policy — now 30 days under the 2024 rules — to read it and cancel for a refund (less small charges) if it isn't what you expected. Use it to actually read the exclusions.

Grace period

extra days after your renewal due date in which you can still pay and keep continuity of waiting periods and benefits. Miss it and the policy lapses.

Renewal, portability & switching

Renewal

paying to continue the policy for another term. Continuity preserves your served waiting periods and accumulated NCB.

Lifelong renewability

the insurer's commitment to renew your policy for life, so you can't be dropped for getting older or having claimed. A feature worth confirming.

Break in policy

a lapse between the expiry of one policy and the start of the next. It can reset waiting periods — avoid it.

Portability

your right to switch to a different insurer while carrying over the waiting-period credit you've already earned, so you don't start the clocks again. Apply at least 45 days before renewal.

Migration

switching to a different plan from the same insurer while keeping your accrued continuity benefits.

Thinking of switching? A five-minute chat with a MITRA advisor will tell you whether portability actually helps in your case — sometimes staying put is the better move, and we'll say so.

Regulator, tax & grievance

IRDAI

the Insurance Regulatory and Development Authority of India, the statutory body that regulates insurers and protects policyholders. Every rule in this glossary traces back to it.

Section 80D

the income-tax deduction for health insurance premiums (and preventive check-ups). For FY 2025–26: up to ₹25,000 for self, spouse and children; an additional ₹25,000 for parents (₹50,000 if they're senior citizens); a ₹5,000 preventive check-up sub-limit sits within these caps. It's available only under the old tax regime, not the new one. This is general information, not tax advice — confirm your position for the current year.

Insurance Ombudsman

a free, official forum to escalate an unresolved complaint (including a rejected claim) against an insurer, without going to court. There are limits on claim size and a time window to file.

Bima Bharosa

the IRDAI's online grievance-redressal portal for policyholder complaints (formerly the IGMS).

Policyholder

in regulatory language, the person the protections are built for. Worth remembering: the rules are on your side more than the fine print suggests.

Ratios and numbers you'll see

Claim Settlement Ratio (CSR)

for health, usually expressed as the share of claims an insurer settled versus received. Useful, but read it with ICR — a high CSR with lots of partial-payment deductions isn't as good as it looks.

Incurred Claims Ratio (ICR)

the total claims an insurer paid as a percentage of premiums it collected. A very low ICR can hint at hard-to-claim policies; a very high one at pricing pressure. Context matters.

Network hospital count

how many hospitals offer cashless with an insurer. A bigger number helps, but the ones near you matter more than the national total.

Quick comparisons

Some pairs are constantly confused. Here's the difference at a glance.

Co-pay vs deductible

Cashless vs reimbursement

Top-up vs super top-up

Individual vs family floater

Common misconceptions

"Cashless means free." No — cashless means you don't pay upfront for covered costs. Co-pay, sub-limits, non-payable items and proportionate deductions still apply. Cashless is about convenience, not zero cost.

"A higher sum insured is all I need." Not if a room-rent limit or sub-limit sits underneath it. A ₹25,00,000 policy with a tight room cap can pay less on a real claim than a ₹10,00,000 plan without one.

"Once I've had the policy a few years, I can't be rejected." Broadly true only after the 60-month moratorium, and even then, proven fraud is still an exception. Honest disclosure at the start is what protects you.

"My employer's cover is enough." It's cover you don't own. It ends with the job, often when you most need continuity — during a health event or a career gap. A personal policy stays.

"I'm young and healthy, so I'll buy later." Waiting periods and premiums both favour buying early. Cover bought while healthy also avoids exclusions on conditions you might develop later.

Frequently asked questions

Keep going

• Life insurance terms → the companion A–Z glossary at /learn/life-insurance-terms
• How health claims actually work → step-by-step at /health/claim-process
• Health Insurance: The Complete Guide → the full topic map at /health/complete-guide
• Talk to a claim expert → /claims

A word on why this glossary exists

Most insurance sites explain these terms to sell you a plan. We explain them because the person who understands their policy before buying is the person we can actually help when they claim — and claims are what MITRA is built around. Insurance is easy to buy. Claims are hard. Understanding the words is the first step to making them effortless.

Not sure which term applies to your situation? A MITRA advisor will walk you through your own policy — free, unbiased, no pressure. Schedule a free call →