Health insurance, TPAs and PM-JAY claims

Hospital and Healthcare Administration (BHA / BBA Hospital Management) · Finance and insurance · free study notes for exams, placements and interviews

In short

Health insurance is the mechanism that pays a hospital for a patient's treatment out of a pooled fund — a commercial insurer's policy, an employer group cover, or a government-funded scheme such as Ayushman Bharat PM-JAY. Third Party Administrators (TPAs) are IRDAI-licensed service companies that sit between insurer, hospital and patient to run cards, pre-authorisation and claim processing, while PM-JAY claims flow through the National Health Authority's own IT rails to a State Health Agency. For a hospital administrator this is the single largest source of revenue and of revenue leakage, so it is examined in BHA/BBA(HM) papers on health insurance and healthcare financing, and tested hard in placement rounds for insurance-desk, TPA-coordinator, credit-billing, claims-processing and empanelment roles at Apollo, Fortis, Max, Manipal, Narayana Health, Medi Assist, Vidal Health, Star Health, Niva Bupa and the public-sector insurers.

Explained

Structure of health financing in India

Out-of-pocket expenditure (OOPE) still funds a large share of health spending in India; insurance exists to cut catastrophic OOPE. National Health Accounts estimates have shown OOPE falling over the last decade — quote the latest NHA estimate rather than a remembered figure.
Three financing channels: (1) government-funded schemes — PM-JAY and state schemes, CGHS for central employees, ECHS for ex-servicemen, ESIC (employees' medical care, now governed by the Code on Social Security, 2020, which replaced the former ESI Act); (2) commercial insurance — individual, family floater and group policies; (3) self-pay/OOPE and employer self-funded trusts.
Regulator: the Insurance Regulatory and Development Authority of India (IRDAI), under the Insurance Act, 1938 and the IRDAI Act, 1999. Products, TPAs and grievance handling are governed by IRDAI regulations and the Master Circular on Health Insurance Business (May 2024), which consolidated earlier circulars.
Who sells health cover: general insurers, standalone health insurers (Star Health, Niva Bupa, Care, ManipalCigna, Aditya Birla Health) and life insurers for fixed-benefit products.
GST position (since 22 September 2025): premiums on individual life and health insurance policies, including family floater and senior-citizen policies, are exempt from GST; group/corporate health policies continue to attract 18%. Hospital room charges above the notified threshold and non-clinical services have their own treatment — check the current rate notification.
Tax relief: premium paid for self, family and parents is deductible under the health-insurance premium provision of the Income-tax Act, 2025 (which replaced the 1961 Act from 1 April 2026 and renumbered all sections — this was section 80D under the old Act); the deduction is available only under the old regime, with a higher ceiling for senior citizens. Quote the current section number from the Act itself.

Anatomy of a health insurance policy

Indemnity vs benefit: indemnity policies reimburse actual hospitalisation expense up to the sum insured; fixed-benefit policies (critical illness, hospital daily cash, personal accident) pay a stated lump sum irrespective of the bill, and both can be claimed for the same event.
Sum insured (SI): the maximum liability per policy year — individual (per person) or family floater (shared across members, cheaper but exhaustible by one illness).
Cost-sharing clauses: deductible (amount the insured bears before cover starts), co-payment (a fixed percentage of every claim borne by the insured, common in senior-citizen and zone-based policies), sub-limits (caps on room rent, cataract, maternity, ICU, consumables).
Waiting periods: initial 30 days (accidents excepted); specific/named diseases typically 24 months; pre-existing diseases (PED) — IRDAI has capped the PED waiting period at a maximum of 36 months; maternity 9–48 months as per product.
Moratorium: after 60 months of continuous cover, the insurer cannot repudiate a claim on grounds of non-disclosure or misrepresentation, except for proven fraud or a permanent exclusion.
Standardised exclusions: IRDAI's standardisation guidelines bar insurers from excluding treatments like genetic disorders, mental illness, age-related degeneration and internal congenital disease wholesale; what may be excluded, and how a specific disease may be permanently excluded with consent, is prescribed.
What is payable: in-patient hospitalisation (minimum 24 hours), day-care procedures (cataract, dialysis, chemotherapy, lithotripsy — no 24-hour rule), pre-hospitalisation (usually 30 days) and post-hospitalisation (usually 60 days), ambulance, modern treatments (robotic surgery, oral chemotherapy, stem cell therapy) now mandatorily covered subject to limits, and AYUSH treatment in a recognised hospital without sub-limits.
What is not payable: non-medical/consumable items in IRDAI's standard list (gloves, administration charges, attendant food, toiletries), cosmetic treatment, OPD unless the product covers it, and treatment outside the policy period.
Continuity features: no-claim/cumulative bonus (SI increment per claim-free year), restoration/refill of SI, portability to another insurer with credit for waiting periods already served, migration within the same insurer, and lifelong renewability. IRDAI removed the maximum age for *buying* a health policy in 2024. The free-look period is now 30 days for all policies, and a Customer Information Sheet (CIS) summarising cover, exclusions and claim process must be given with every policy.
Standard products: Arogya Sanjeevani (standard indemnity, uniform wording across insurers), Saral Suraksha Bima (standard personal accident) and the standard travel product — designed for comparability.
Service turnaround (2024 Master Circular): cashless pre-authorisation decision within 1 hour of request and final discharge authorisation within 3 hours; claims otherwise to be decided within the stipulated period after the last document. The circular also curtails the old practice of proportionate deduction for room-category upgrades — check the current wording, as circulars are revised.

TPAs: licence, functions and limits of authority

A TPA is licensed under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016 (amended 2019): a company registered under the Companies Act with a minimum paid-up equity capital of ₹4 crore (and working capital/net worth never below ₹1 crore), a licence granted for three years and renewable, and a Chief Administrative Officer plus a Chief Medical Officer.
Functions: issuing health ID cards, maintaining a 24×7 call centre, hospital network/PPN tie-ups and rate negotiation, pre-authorisation, claim scrutiny and adjudication recommendation, provider payment on the insurer's behalf, and MIS to the insurer.
Hard limit: a TPA cannot repudiate (reject) a claim and cannot settle a claim on its own authority — repudiation is the insurer's decision; a TPA also cannot collect any fee from the policyholder and is paid only by the insurer. Since the 2019 amendment, the policyholder may be offered a choice of TPA where the insurer uses more than one.
Alternative: many insurers now run in-house claim/health administration teams instead of a TPA, which usually gives faster turnaround and fewer hand-offs but removes the TPA's multi-insurer network scale.
Cashless workflow at the hospital's insurance desk: verify ID card and policy → check network/tariff → raise pre-authorisation with diagnosis, line of treatment, estimate and ICD/procedure code → receive authorisation letter (AL) with an approved amount → treat; raise enhancement if the stay or cost exceeds the AL → at discharge submit the final bill, discharge summary, investigation reports and claim form → receive final authorisation → collect only the non-payable/co-pay portion from the patient → submit the physical/digital claim file → payment, with a disallowance statement to be reconciled or appealed.
Reimbursement workflow: the patient pays in full, then files the claim with original bills, discharge summary, prescriptions, reports, KYC and bank details within the notified intimation (usually 24–48 hours for emergency) and submission window.
Cashless Everywhere: a General Insurance Council initiative (2024) allowing cashless treatment at non-network hospitals subject to prior intimation (usually 48 hours before planned, 48 hours after emergency admission) — availability varies by insurer.

Ayushman Bharat PM-JAY: design

Launched 23 September 2018, merging the former RSBY and state schemes; fully government-funded, with central–state cost sharing (commonly 60:40, 90:10 for most north-eastern and Himalayan states, 100% for UTs without legislature).
Cover: ₹5 lakh per family per year on a family floater basis for secondary and tertiary hospitalisation (and day care), with no cap on family size, age or gender and no waiting period for pre-existing conditions — entitlement, not insurance underwriting.
Beneficiaries: deprivation and occupational criteria of the SECC 2011 (rural D1–D5, D7; 11 urban occupational categories), covering about 12 crore families / 55 crore people, plus state-expanded categories. Ayushman Vay Vandana (announced October 2024) extends a separate ₹5 lakh top-up cover to all citizens aged 70 and above regardless of income.
Portability: the entitlement is usable in any empanelled hospital in any participating state. Participation is a state decision — Delhi and Odisha joined in 2025; West Bengal has remained outside; confirm current status before quoting.
Implementation modes: insurance mode (premium paid to an insurer), trust mode (state pays claims from its own fund — now the dominant mode), or mixed mode. An ISA (Implementation Support Agency) or TPA may process claims for the State Health Agency (SHA); the National Health Authority (NHA) is the apex implementing body.
Health Benefit Packages (HBP): the current master list (HBP 2022 and its revisions) contains roughly 1,900+ procedures across 27 specialties, each with a package code, a fixed rate, stratification (by implant, ICU day, age) and a reservation flag — many packages are reserved for public hospitals. There is no balance billing: the package rate is all-inclusive of bed, drugs, consumables, implants, diagnostics, surgeon fees, food and a notified number of follow-up visits, and the patient pays nil.
Empanelment: through the Hospital Empanelment Module (HEM); criteria include a minimum bed strength (commonly 10 in-patient beds for general empanelment, specialty-specific thresholds otherwise), registration under the Clinical Establishments Act or state equivalent, qualified full-time staff, 24×7 nursing, pharmacy, biomedical waste authorisation, fire safety NOC, and a Pradhan Mantri Arogya Mitra (PMAM/Ayushman Mitra) at the help desk.
Rate incentives: HBP guidelines allow a percentage uplift on package rates for NABH entry-level and full NABH accreditation, for teaching/PG hospitals and for hospitals in aspirational districts, with an overall cap. The percentages are notified and revised — use the state's current notification rather than a remembered figure.

The PM-JAY claim cycle, payment and fraud control

Identification: beneficiary verified in the Beneficiary Identification System (BIS 2.0) with Aadhaar-based e-KYC; Ayushman card issued (cumulative card creation has crossed the 30-crore mark; quote the current NHA dashboard figure).
Registration and pre-authorisation: the PMAM registers the case in the Transaction Management System (TMS); the treating doctor selects the package code and uploads mandatory documents and photographs; the SHA/ISA medical officer approves, queries or rejects the pre-auth, normally within a few hours (emergency cases have an expedited/emergency-telephonic route).
Treatment and discharge: discharge entered in TMS with discharge summary, final diagnosis, implant stickers/invoices where applicable and patient satisfaction/feedback capture.
Claim submission and adjudication: the claim is raised in TMS; the claim processing doctor (CPD) checks package appropriateness, document completeness and clinical justification; the claim is approved, queried, partly approved or rejected.
Payment: NHA guidelines require settlement within 15 days for in-state claims and 30 days for portability claims, paid electronically to the hospital's registered account; interest/penalty for delay is provided for in the guidelines. Delays in some states are a known operational issue.
Multiple procedures in one admission: the highest-rated package is paid at 100%, the second at 50% and the third and subsequent at 25%.
Fraud control: the National Anti-Fraud Unit (NAFU) with State and District units (SAFU/DAFU), trigger-based data analytics, field verification, de-empanelment, recovery and penalties; common red flags are impossible gender/age–procedure combinations, abnormal surgery rates, repeat claims on one card and ghost beneficiaries.
Grievance redressal: the Centralised Grievance Redressal Management System (CGRMS) with district, state and national grievance redressal committees and nodal officers, plus the 14555 helpline.

Digital rails and the hospital insurance desk

ABDM: the ABHA number (14-digit health account), Health Facility Registry (HFR) and Healthcare Professionals Registry (HPR) provide the identity layer for linked health records.
NHCX (National Health Claims Exchange): a gateway built by NHA with IRDAI to carry coverage eligibility, pre-auth and claim messages between hospitals, insurers and TPAs in a common FHIR-based specification, replacing per-payer portals, email and courier. Rollout is phased — onboarding status varies by payer and hospital.
Private-payer standardisation: standard treatment guidelines, ICD-10/ICD-11 diagnosis coding and standardised non-payable lists cut dispute volume; PPN (preferred provider network) tariffs fix the rate card the hospital may bill.
Insurance desk metrics to track: pre-auth turnaround time, approval and enhancement rate, disallowance (deduction) rate, outright denial rate, appeal recovery rate, and claim realisation percentage. (Day-wise receivable ageing and billing mechanics belong to the revenue-cycle topic.)
Grievance escalation for an insured patient: insurer's grievance officer → IRDAI Bima Bharosa portal → Insurance Ombudsman under the Insurance Ombudsman Rules, 2017 (as amended), which handles personal-line complaints with an award limit of ₹30 lakh → consumer commission under the Consumer Protection Act, 2019.

Key points

Indemnity cover — reimburses actual expense up to SI; benefit cover — pays a fixed sum regardless of the bill, and both are payable together.
Family floater — one SI shared by the family; cheaper, but one major illness can exhaust it for everyone.
Deductible — borne before cover begins; co-payment — a fixed percentage of every claim borne by the insured.
PED waiting period — capped at a maximum of 36 months; moratorium — after 60 months of continuous cover, no repudiation for non-disclosure except proven fraud.
Day-care procedure — payable without the 24-hour hospitalisation rule; domiciliary hospitalisation — home treatment where a bed was unavailable or the patient immovable.
Portability — switching insurer with credit for waiting periods already served; migration — switching product within the same insurer.
Free-look — 30 days to return a policy; CIS — mandatory one-page summary of cover and claim procedure.
Cashless turnaround — pre-auth decision in 1 hour, final discharge authorisation in 3 hours per the 2024 Master Circular.
TPA — IRDAI-licensed, ₹4 crore minimum paid-up equity capital, three-year licence; it cannot reject a claim and cannot charge the policyholder.
Non-medical expenses — IRDAI's standard list of consumables that the patient always pays; the biggest single source of hospital disallowance.
PM-JAY — ₹5 lakh per family per year, secondary and tertiary hospitalisation, no family-size/age cap, no PED waiting period, fully government funded.
Ayushman Vay Vandana — ₹5 lakh top-up for all citizens aged 70+, irrespective of income.
HBP — roughly 1,900+ packages across 27 specialties at fixed all-inclusive rates; some reserved for public hospitals; no balance billing.
Multiple-procedure rule — highest package 100%, second 50%, third onwards 25%.
PM-JAY settlement — 15 days in-state, 30 days for portability claims, per NHA guidelines.
Trust mode vs insurance mode — state pays claims from its own fund vs state pays a premium to an insurer; trust mode now dominates.
NAFU/SAFU/DAFU — the anti-fraud machinery; penalties and de-empanelment follow trigger-based analytics and field verification.
NHCX — FHIR-based national claims exchange connecting hospitals, insurers and TPAs on one specification.

Formulas and examples

Admissible claim = (Eligible medical expenses − non-payable items) − proportionate deduction − deductible, then × (1 − co-pay rate); capped at the available sum insured
Proportionate factor = Eligible room rent per day ÷ Actual room rent per day (applied to associated medical expenses only, where the policy permits it)
Incurred Claims Ratio (ICR) % = Net incurred claims ÷ Net earned premium × 100
Claim Settlement Ratio (CSR) % = Claims settled ÷ (Claims settled + claims repudiated + claims withdrawn) × 100 — i.e. of claims decided in the year
Combined ratio = (Net incurred claims + management and commission expenses) ÷ Net earned premium
Claim realisation rate % = Amount received from payer ÷ Amount billed to payer × 100; Disallowance rate % = 100 − realisation rate
PM-JAY blended package = P₁ × 100% + P₂ × 50% + Σ(P₃…Pₙ) × 25%, then × (1 + accreditation/location incentive)
Cumulative (no-claim) bonus SI after n claim-free years = Base SI × (1 + b)ⁿ or Base SI × (1 + n·b), as the wording specifies; b = bonus rate

Symbols: SI = sum insured (₹), P = package rate (₹), b = bonus rate per claim-free year.

Example 1 — Cashless claim with room-rent sub-limit and co-pay. SI ₹5,00,000; eligible room rent 1% of SI per day = ₹5,000; the patient chose a room at ₹8,000/day for 4 days. Final bill ₹2,40,000 = room rent ₹32,000 + associated medical expenses ₹1,70,000 + non-payable consumables ₹38,000. Policy co-pay 10%.

Room rent allowed = 4 × ₹5,000 = ₹20,000.
Proportionate factor = 5,000 ÷ 8,000 = 0.625 → associated expenses allowed = 1,70,000 × 0.625 = ₹1,06,250.
Non-payables allowed = ₹0.
Admissible before co-pay = 20,000 + 1,06,250 = ₹1,26,250; co-pay 10% = ₹12,625.
Insurer pays ₹1,13,625; the patient pays ₹1,26,375 — more than half the bill, purely from the room upgrade and consumables. (Had the patient stayed within the ₹5,000 room, the allowed amount would be 20,000 + 1,70,000 = ₹1,90,000, less 10% co-pay = ₹1,71,000.)

Example 2 — Top-up versus super top-up. Base policy ₹5,00,000. Option A: top-up ₹20,00,000 with a per-claim deductible of ₹5,00,000. Option B: super top-up ₹20,00,000 with an aggregate (annual) deductible of ₹5,00,000. Three hospitalisations in the year: ₹3,00,000, ₹4,00,000, ₹6,00,000 (total ₹13,00,000).

Option B (super top-up): claim 1 — base pays ₹3,00,000. Claim 2 — base has ₹2,00,000 left, pays it; cumulative spend crosses ₹5,00,000, so the super top-up pays the balance ₹2,00,000. Claim 3 — base exhausted, super top-up pays ₹6,00,000. Patient pays ₹0.
Option A (ordinary top-up): claim 1 — base pays ₹3,00,000, top-up nil. Claim 2 — base pays its remaining ₹2,00,000; the claim of ₹4,00,000 alone does not cross the ₹5,00,000 per-claim deductible, so the top-up pays nil → patient pays ₹2,00,000. Claim 3 — top-up pays 6,00,000 − 5,00,000 = ₹1,00,000 → patient pays ₹5,00,000. Patient pays ₹7,00,000.

Example 3 — Insurer performance ratios. Net earned premium ₹1,200 crore; net incurred claims ₹1,020 crore; management and commission expenses ₹260 crore. Claims decided in the year: 1,70,500 settled, 8,500 repudiated.

ICR = 1,020 ÷ 1,200 = 85.0%.
Combined ratio = (1,020 + 260) ÷ 1,200 = 1,280 ÷ 1,200 = 106.7% → an underwriting loss of 6.7% of premium, to be covered by investment income.
CSR = 1,70,500 ÷ 1,79,000 = 95.25%.

Example 4 — PM-JAY blended package with incentive. One admission needs three packages: ₹60,000, ₹20,000 and ₹10,000. The hospital holds full NABH accreditation; assume the state's notified uplift is 15% (verify the current rate).

Blended = 60,000 + (0.50 × 20,000) + (0.25 × 10,000) = 60,000 + 10,000 + 2,500 = ₹72,500.
With incentive = 72,500 × 1.15 = ₹83,375 payable to the hospital, ₹0 to the patient, due within 15 days for an in-state claim.

Example 5 — Insurance desk disallowance analysis. In a month the hospital billed 1,000 cashless claims worth ₹4.50 crore and received ₹4.14 crore; 25 claims were denied outright.

Disallowance = 36,00,000 ÷ 4,50,00,000 = 8.0%; realisation rate = 92.0%.
Denial rate = 25 ÷ 1,000 = 2.5%.
Split of the ₹36 lakh: non-payable consumables ₹21 lakh (58%), room-rent proportionate deduction ₹9 lakh (25%), documentation/clinical-justification deductions ₹6 lakh (17%) — so 58% is recoverable from the patient only if counselled before admission, and 17% is avoidable by better file preparation.

Feature	Commercial health policy	PM-JAY
Funding	Policyholder/employer premium	Government (Centre–State share)
Entitlement	Sum insured chosen; underwriting applies	₹5 lakh per family per year; no underwriting
PED waiting	Up to 36 months	None
Pricing to hospital	Negotiated/PPN tariff, itemised bill	Fixed HBP package rate, all-inclusive
Patient payment	Co-pay, deductible, non-payables, sub-limit gaps	Nil — balance billing prohibited
Processor	Insurer in-house team or TPA	SHA/ISA or TPA on NHA's TMS
Grievance route	Insurer → Bima Bharosa → Ombudsman → consumer commission	CGRMS, district/state/national committees, 14555

Where it is used

Hospital insurance/TPA desk and credit billing: pre-auth drafting, enhancement, discharge clearance, disallowance reconciliation and appeals at Apollo, Fortis, Max, Manipal, Narayana Health, Aster and large trust hospitals.
TPAs and insurers: Medi Assist, Vidal Health, Paramount, FHPL, Ericson, Raksha and insurer in-house teams (Star Health, Niva Bupa, HDFC Ergo, ICICI Lombard) hire BHA graduates as claim processors, network/provider-relations executives and medical-audit coordinators.
PM-JAY ecosystem: State Health Agencies, ISAs, claim processing doctors, PMAM/Ayushman Mitra roles, empanelment and anti-fraud units under NHA and the state schemes (MJPJAY in Maharashtra, CMCHIS in Tamil Nadu, Aarogyasri/NTR Vaidya Seva in Telangana and Andhra Pradesh, Karunya/KASP in Kerala).
Corporate/group health: employee benefit administration, broker and consulting roles (Marsh, Aon, Policybazaar for Business) sizing group covers using claims data and ICR.
Hospital strategy and finance: payer-mix analysis, decision to accept or exit a scheme based on package rate versus cost per case, and NABH accreditation taken partly for the PM-JAY rate uplift and better PPN tariffs.
Health informatics: ABDM/NHCX integration, HIS–payer interfacing, ICD coding and claims data analytics.

Interview questions

Q: What is the difference between cashless and reimbursement? A: In cashless the insurer/TPA pays the network hospital directly against a pre-authorisation, and the patient settles only non-payables and co-pay; in reimbursement the patient pays the whole bill and claims it back with original documents.
Q: Can a TPA reject a claim? A: No — a TPA may scrutinise, query and recommend, but repudiation is solely the insurer's decision, and a TPA cannot charge the policyholder anything.
Q: What is the moratorium period and why does it matter to a patient? A: After 60 months of continuous cover, the insurer cannot deny a claim on grounds of non-disclosure or misrepresentation except for proven fraud or an agreed permanent exclusion — so long-held policies are far safer.
Q: Why is the room category so important in a health claim? A: Many policies cap room rent and, where permitted, scale down the associated medical expenses in the same proportion, so a room upgrade can cut the admissible amount sharply even though the treatment is covered.
Q: A patient had a cataract surgery in 6 hours — is it payable? A: Yes, cataract is a listed day-care procedure and the 24-hour hospitalisation condition does not apply.
Q: What does an ICR of 110% tell you? A: The insurer paid ₹110 in claims for every ₹100 of earned premium — an underwriting loss on that line, pointing to under-pricing, adverse selection or claim leakage.
Q: How does PM-JAY pay a hospital, and can the hospital charge the patient for an implant? A: It pays a fixed, all-inclusive HBP package rate to the hospital after TMS adjudication; balance billing is prohibited, so no charge to the patient for implants, drugs, diagnostics or food.
Q: Three procedures are done in one PM-JAY admission — how is payment computed? A: The highest package at 100%, the second at 50% and the third onwards at 25%, then adjusted for any applicable accreditation or location incentive.
Q: What is the difference between a top-up and a super top-up? A: A top-up applies its deductible to each claim separately; a super top-up applies it to the aggregate of claims in the policy year, so it triggers far more often.
Q: What is NHCX and why does it matter to a hospital? A: It is the NHA–IRDAI national claims exchange that carries eligibility, pre-auth and claim messages in a common FHIR-based format, replacing separate payer portals and courier files and cutting turnaround time.
Q: As an insurance desk manager, how would you cut disallowances by half? A: Pre-admission counselling on room eligibility and the non-payable list with a signed estimate, a pre-auth checklist with ICD/procedure codes and clinical justification, daily tracking of enhancement triggers, and a weekly deduction-reason analysis fed back to the treating units with a formal appeal for unjustified deductions.
Q: Does a PM-JAY beneficiary with a pre-existing diabetic foot have to wait? A: No — PM-JAY covers pre-existing conditions from day one; it is an entitlement scheme, not an underwritten insurance product.

Common mistakes

Confusing Claim Settlement Ratio (how many claims an insurer decided in the claimant's favour) with Incurred Claims Ratio (claims paid as a share of premium) — they measure completely different things.
Treating the TPA as the decision-maker on rejection, or assuming the TPA can be paid by the hospital or the patient.
Quoting the PED waiting period as 48 months or the moratorium as 8 years — both were revised downward to 36 and 60 months respectively.
Saying PM-JAY covers OPD, or allowing any amount to be collected from a PM-JAY patient — it is hospitalisation and day care only, and strictly no balance billing.
Applying the proportionate deduction to the whole bill, including implants and pharmacy, instead of only to the associated expenses the policy defines — and ignoring that IRDAI's 2024 circular has curtailed the practice.
Forgetting that pre- and post-hospitalisation expenses and ambulance charges are claimable, and that they come out of the same sum insured.
Quoting GST at 18% on an individual health policy — individual life and health premiums have been GST-exempt since 22 September 2025, while group policies still attract 18%.