Hospital bill: Why did I have to pay before the insurer stepped in?
I paid my premium on time, so why did I still have to pay ₹50,000 from my pocket during hospitalization? No one told me about the deductible clause. Is this fair?
-Name withheld on request
This is a very valid concern and one that many policyholders face, especially during the first health insurance claim. It feels confusing—and even unfair—when you’ve done everything right: paid your premium, maintained your policy, and still find yourself paying a large amount out-of-pocket at a time of stress.
The core of this issue lies in understanding how health insurance policies are structured. While we tend to focus on the sum insured, we often miss reading or understanding deductibles and other limits that affect claim settlement.
A deductible is a fixed amount that you, the policyholder, agree to pay before the insurance company starts covering the remaining expenses. For instance, if your policy has a ₹50,000 deductible and your total hospital bill is ₹1.2 lakh, you’ll have to pay the first ₹50,000 yourself. The insurance company will cover only the balance of ₹70,000.
This clause is not necessarily hidden, but it is often not explained clearly at the time of purchase. It is usually found in the terms and conditions section of the policy document, and unless you ask or read carefully, it may go unnoticed.
In many cases, sales representatives or agents highlight the policy’s benefits but may not focus on limitations like deductibles or co-payments. This lack of upfront clarity is what causes disappointment during claims.
There are two types of policies where deductibles are commonly found: top-up or super top-up plans and affordable or budget plans. In order to keep the premium low, this is generally added to be discovered at the time of the claim.
As a policyholder, you deserve to be informed about all of these. But in reality, many people are unaware until they make their first claim—and by then, it’s too late to make changes.
From a transparency point of view, no, it isn’t fair if you weren’t clearly informed. While insurers include these clauses to manage risk and pricing, it’s equally important that customers understand what they are buying.
The solution lies in better awareness and asking the right questions when buying a policy. Always check: What are the exclusions? Are there any deductibles or sub-limits? What is the actual amount you’ll need to pay in case of hospitalization?
Being aware of these details can prevent unpleasant surprises and help you choose a plan that truly fits your needs.
Shilpa Arora is a co-founder of Insurance Samadhan.
