What Really Happens When You Claim Insurance in India

A Familiar Story

For most of us, health insurance feels like a safety net: something we buy because we know we should but hope we'll never actually need. It sits in our files or inbox, untouched for years, until suddenly life forces us to use it.

When Arun’s father was rushed in for a bypass surgery, the family felt relieved knowing they had a ₹5 lakh health insurance cover.

The surgery went smoothly, the hospital sent the bill to the insurer, and the family expected it to be “cashless.” But when the discharge summary arrived, Arun still had to swipe his card for ₹1.4 lakh out of pocket.

Most people assume health insurance pays the hospital bill in full. Reality is very different.

The Expectation vs The Reality

Many people think health insurance means the insurer pays the full hospital bill. In reality, claims can be tricky. Fine print, hidden rules, and limits quietly decide how much you actually get.

Arun’s story is not unique. Thousands of Indian families go through this every day.

A ₹5 lakh cover doesn’t always mean ₹5 lakh in your hand!!! - Shocker!

Behind the Scenes of a Claim

Here’s what actually plays out:

• The hospital sends a “pre-authorization” to the insurer or TPA.
• The insurer checks the file against the policy terms, sub-limits, and past health records.
• The approval comes with conditions, sometimes capping room rent, doctor’s fees, or implant costs.
• The final settlement happens at discharge, and that’s when families discover what wasn’t covered.

In Arun’s case:

• His father chose a room that exceeded the “room rent limit” by 20%.
• As per policy rules, all doctor and surgeon fees got proportionately reduced.
• The end result was a ₹1.4 lakh shortfall.

Even a cashless hospital experience can leave you paying thousands unexpectedly.

The Patterns Nobody Tells You About

When we at Policygaido studied 2+ million real claim experiences across India, we found repeating patterns:

• Room rent traps → 1 in 4 claims saw deductions just because of exceeding room rent caps.
• Hidden copays → Especially in senior citizen policies, copays of 20–30% kick in silently.
• Sub-limits on common treatments → Cataract, knee replacement, and maternity all come with fixed ceilings.
• Cashless is not full payment → Even in “network hospitals,” insurers often approve only part of the bill.

These aren’t rare exceptions. They’re built into the system.

Why Brochures Won’t Warn You

If you read an insurance brochure, everything looks rosy. “Cashless at 10,000+ hospitals,” “Comprehensive cover for major illnesses.”

But brochures are marketing documents. They don't highlight the live experience of filing claims. That's why most people learn about exclusions only at the worst possible moment: when a loved one is on a hospital bed.

How our GaidoAI Tries to Fix This

At Policygaido, we built our AI to flip the lens. Instead of only reading policy wordings, we analyze:

• Real claim approvals and rejections across insurers.
• Patterns of where people lose money, such as room rent, exclusions, and copays.
• Hospitals where approvals go smoothly vs where disputes are frequent.

So when we recommend a plan, it’s not just “cheapest premium” or “highest cover.” It’s about what will actually get paid when you need it most.

Curious how your policy would actually perform in a real claim? With Policygaido, you can:

• Test Before You Buy: Try out real claim scenarios on any plan before making a purchase.
• Upload Policy: Instantly check your existing policy for hidden traps, copays, sub-limits, and potential claim pitfalls.

It's like a "claim rehearsal": you know what to expect, avoid nasty surprises, and pick plans that truly work for you.

Try it out and see exactly how your insurance behaves when it matters most.

Reflection: What You Can Take Away

Insurance isn’t about “having a 5 lakh cover.” It’s about knowing how much of that 5 lakh will actually come through in a real claim.

For Arun, that painful ₹1.4 lakh bill was a lesson. For you, it doesn’t have to be.

👉 Next time you look at insurance, ask not just “what’s covered?” but “what’s usually paid?” That single shift can save you lakhs and a lot of heartbreak.