Key reasons for reduced payouts :
Policies have several exclusions and limitations. If the policyholder does not take these into account at the time of purchase, it can result in a lesser claim settlement amount and an unpleasant claims experience.
Sub-limits and caps: Some policies impose sub-limits on room rent, surgeries, and treatments. Older policies, for instance, offered room rent coverage for a fixed amount or up to 1 per cent of the sum insured. If a policyholder opts for a higher-cost room than allowed, the insurer may make a lower claim payout.
Staying in a higher-category room can lead to a proportionately lower payout on the entire bill.
Copayment and deductible:Many policies, especially for senior citizens, include copayments. If the copayment is 20 per cent, the insurer will pay 80 per cent of the bill, and the insured must cover 20 per cent out of his pocket.
For policies with a deductible, such as Rs 1 lakh, the insured must pay bills up to this amount. The insurer covers only bills above that threshold.
Exclusions: Certain conditions or treatments, such as cosmetic procedures, are not covered by policies. A claim for these exclusions will not be paid.
Consumables: Items like PPE (personal protection equipment) kits, gloves, and masks used during treatment are often excluded. Consumables can account for 7-10 per cent of the total bill. Traditionally, many policies did not cover consumables.
In order to get the full coverage, you need to choose the right product according to age and your health condition. Health insurance is a very person specific product now a days with so many features and options accross many insurers.
