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Understand Eligibility for Health Insurance

Updated On Dec 04, 2020

Who is Eligible For Health Insurance?

Picking well-suited health insurance can be a tough job. The eligibility of the policyholder is a critical condition to be considered while investing in a health insurance policy. Knowing and evaluating all the factors that dictate eligibility, before choosing or even considering a plan is crucial to selection simpler.  

Eligibility Factors For Health Insurance in India

If we consider the ideal situation there are as such no eligibility factors which are hard and fast but in reality the following two factors slightly affect eligibility. 

  • Minimum Entry Age: The minimum age to avail of the benefits of health insurance for your child under a child plan is usually 16 days to 18 years. Entry age of a policy for adults ranges from 18 up to 65 years. It can also be 70 years and above based on the plan and insurer. 
  • Pre-Existing Medical Conditions: If you are purchasing health insurance after the age of 45, you may have to go through various medical tests before getting a health cover. If the policyholder is not asked for the medical tests, then he/she has to submit a declaration disclosing his/her pre-existing conditions.  These preconditions or revelations by medical tests determine whether a policy is accessible to a policyholder.

Common Myths About Eligibility For Health Insurance Plans

There are certain myths in the society that have developed over time and the very same are listed below:

  • Smoking Makes Me Ineligible For a Health Insurance Policy: A major section of people with smoking or drinking issues believe they are ineligible for insurance. However, that’s not true. Since smoking puts you at a higher risk of having medical problems, so maybe you would be required to pay a higher premium or go through stricter medical tests. But you are not ineligible for health insurance.
  • Declaring All Pre-existing Health Conditions Would Make Me Ineligible For Health Insurance: Your insurance company can offer you good competitive premium rates only if you are in good health. True. But non-disclosure of pre-existing health conditions can lead to dismissal of your claim by the company. Instead, if you disclose, the company will charge you a higher premium and the existing condition would be covered by the policy.
  • Pregnancy is Not Eligible For Coverage Under Any Health Insurance Policy: True until a few years ago as companies rarely covered these claims that were considered highly expected. But that is an absolute myth now. While there could be some conditions attached, like waiting periods until such a claim is covered or coverage for 1st pregnancy only, etc. but Insurers now mostly cover pregnancy.
  • My Entire Hospital Bill is Eligible For Coverage Under Health Insurance: Seems true, but the coverage of hospital bills is subject to policy conditions. The policy doesn’t cover consumables like bandages, oxygen mask, nylon gloves, thermometer, etc. In some cases, there are sub-limits on room rent, etc. So anything above and beyond is eligible for reimbursement by the insurance company.
  • Non-Renewal on a Due Date Makes You Ineligible for Any Benefits: Even if the policy is not renewed on the due date, the policyholder can renew it within 15 days from the policy expiry date and that would be considered “continuity” for benefits like coverage for pre-existing conditions, waiting periods, etc. However, any claim for the period in between due date and date of actual renewal will not be covered even after renewal.
  • You Are Eligible to Claim Only After 24 Hours Hospitalisation: With advancements in medical science over 100 treatments like lithography, cataract surgery, chemotherapy, etc can be done in a few hours. So, mostly all insurance companies allow coverage for treatments with less than a day's hospitalisation.


A health insurance policy usually covers medical expenses, pre-hospitalisation and post-hospitalisation, domiciliary expenses, ambulance charges, room rent, ICU charges, and medicines. There are some common eligibility criteria for these health insurance policies as mentioned above but there are some special ones and it is recommended that you read the description carefully for those special points.

Disclaimer: This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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