Glossary
The words in your claim letter,
in plain English.
Short definitions of the terms insurers use when they reject or cut a health claim, with the rule behind each where there is one.
- AYUSH
- Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy. IRDAI requires insurers to have a board-approved policy placing AYUSH treatment at par with other treatments. Read the guide
- Bima Bharosa
- IRDAI’s online grievance system (bimabharosa.irdai.gov.in). A complaint goes to the insurer first and can be escalated to IRDAI’s grievance cell. Helpline 155255. Read the guide
- Cashless claim
- A claim where the insurer or TPA pays a network hospital directly, after approving a pre-authorisation request. The request must be decided within 1 hour, and final discharge approval within 3 hours. Read the guide
- Claims Review Committee
- A committee of the insurer that must approve every repudiation of a health claim under IRDAI’s 2024 health insurance master circular. Read the guide
- Co-payment (co-pay)
- A fixed share of each admissible claim that you pay yourself, such as 10% or 20%. It applies only if your policy schedule says so.
- Consumables and non-payable items
- Items like gloves, masks and kits that many policies don’t pay for. IRDAI’s standard list was repealed in 2024, so your policy’s own list decides; a consumables add-on pays what its wording says. Read the guide
- Contra proferentem
- A rule courts use when reading contracts: if a policy term is ambiguous, it is read against the party that wrote it, which is the insurer.
- Customer Information Sheet (CIS)
- A short summary of your policy in IRDAI’s set format: cover, exclusions, waiting periods and claim timelines. If it conflicts with the policy document, the policy document prevails.
- Day care treatment
- A procedure done in under 24 hours because of advances in technology, which would otherwise have needed a longer stay. Most policies cover it even though the stay is under 24 hours. Read the guide
- Deductible
- An amount you bear before the policy starts paying, found in top-up and some other policies. It applies only if your policy states it.
- Discharge summary
- The hospital’s record of your diagnosis, treatment and condition at discharge. It is usually the most important document in a claim dispute.
- Free look period
- 30 days from receiving a new policy of one year or more, during which you can return it if the terms don’t suit you.
- Grace period
- Time allowed after the renewal date to pay the premium without a break in cover: 15 days for monthly premiums and 30 days for other modes.
- Grievance Redressal Officer
- The insurer’s officer who handles complaints. The insurer must acknowledge a complaint immediately and resolve it within 14 days. Read the guide
- Insurance Ombudsman
- A free forum for disputes with insurers under the Insurance Ombudsman Rules 2017. It can award up to ₹50 lakh including expenses; you must file within one year of the insurer’s final reply. Read the guide
- Migration
- Moving to another health product with the same insurer. Your credit for waiting periods and the moratorium carries over. Read the guide
- Moratorium period
- After 60 continuous months of cover, including ported and migrated years, an insurer can’t contest a policy or claim for non-disclosure or misrepresentation, except for established fraud. Read the guide
- Network hospital
- A hospital that has an agreement with your insurer or TPA for cashless treatment. You can usually still claim reimbursement for treatment at other hospitals.
- Non-disclosure
- Not telling the insurer something the proposal form asked about, such as an earlier illness. It is limited to what the form asked, and can’t be used after the 60-month moratorium except for fraud. Read the guide
- Partial settlement
- When the insurer pays only part of a claim. Each deduction must refer to the specific policy clause behind it. Read the guide
- Portability
- Moving your health policy to a new insurer at renewal. Credit for waiting periods and the moratorium carries over. Apply 30 to 60 days before renewal. Read the guide
- Pre-existing disease (PED)
- A condition diagnosed by a physician, or for which a physician advised or gave treatment, within 36 months before the policy started. Its waiting period is capped at 36 months. Read the guide
- Proportionate deduction
- A cut applied to other charges in the bill when you stay in a room above your policy’s room-rent limit. The policy must clearly state it, and which charges it applies to. Read the guide
- Proposal form
- The form you filled in to buy the policy. Your duty to disclose is limited to what it asked. The insurer must send you a copy within 15 days of accepting the proposal.
- Reasonable and customary charges
- A limit most policies place on charges: the standard charges of the specific hospital, consistent with prevailing charges in the area. Read the guide
- Reimbursement claim
- A claim where you pay the hospital and the insurer pays you back. It must be settled within 15 days of submission, with interest if late. Read the guide
- Repudiation
- The insurer’s refusal of a claim. It must be communicated with full details, referring to the specific terms of the policy. Read the guide
- Room rent capping
- A limit on the room charge per day, often a percentage of the sum insured. It can lead to proportionate deductions if you choose a costlier room. Read the guide
- Sub-limit
- A cap on what the policy pays for a particular treatment or item, below the sum insured. It must be stated in the policy. Read the guide
- Sum insured
- The most the policy will pay in a policy year.
- TPA (third party administrator)
- A company registered with IRDAI that processes health claims for insurers. Complaints about a claim still go to the insurer.
- Waiting period
- Time after the policy starts during which certain claims aren’t paid. The PED waiting period and specific-disease waiting periods are each capped at 36 months, and specific waiting periods never apply to accidents. Read the guide
General information, based on IRDAI’s 2024 master circulars and regulations and the Insurance Ombudsman Rules 2017 as amended. Your policy wording decides many of these terms. Last reviewed 9 November 2026.
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