How Health Insurance Coverage Varies Between Family Members


Family health insurance is of utmost important to families in current times. However, many people are not aware that the family health insurance coverage invariably varies among family members. In this blog, let us discuss about how family health insurance coverage differs between various family members.

The Landscape of Family Health Insurance in India

Health Insurance Coverage

Family health insurance is an crucial element in the financial planning for Indian families. These policies are specially curated to encompass the health and well-being of the entire family under a single insurance umbrella. They offer comprehensive coverage against medical expenses, serving as a financial cushion during unforeseen medical crises.

Coverage Variations Among Different Family Members

One key aspect that many people tend to overlook is the significant variation in coverage among different family members. This variation is influenced by several factors, including age, health conditions, and specific policy terms. It’s crucial for policyholders to understand these variations in coverage to make the most of their insurance policy.

Here are some key factors that influence coverage variations among family members:


Age plays an important role in determining the extent of coverage variations. Children, adults, and elderly family members often require different types of medical attention, leading to distinct levels of coverage. For instance, even the best health insurance for family may provide various benefits like maternity benefits for young couples but not for older family members.

Pre-Existing Conditions:

Family members with pre-existing medical conditions may have certain treatments or expenses excluded from their coverage. These exclusions can significantly affect the overall coverage provided to that family member.

Sum Insured:

The sum insured, which represents the total coverage amount, is another key determinant of coverage variations. Different family members may be allocated different portions of the sum insured, based on the policy’s terms and conditions.

Riders and Add-Ons:

Policyholders can opt for additional riders or add-ons to enhance coverage for specific family members. For example, critical illness riders can provide additional coverage for adults, while vaccination coverage may be chosen for children.

Maternity Coverage:

Family health insurance policies typically offer maternity coverage for young couples planning to start a family. This benefit may not be applicable to older family members.

Network Hospitals:

The availability of network hospitals may also influence coverage. Certain network hospitals may specialize in pediatric care, while others may focus on geriatric healthcare.

Waiting Periods:

Some policies include waiting periods before specific types of coverage become active. For example, maternity coverage often has a waiting period, meaning it won’t apply until a specified duration after the policy’s inception.

Coverage for Specific Ailments:

Family members may have varying needs for coverage related to specific ailments or conditions. For example, a child might need coverage for vaccinations and dental care, while an older family member may require coverage for age-related conditions.

Steps to Keep in Mind When Making a Family Health Insurance Claim

While family health insurance can be a lifeline during medical emergencies, the claims process can sometimes be intricate. Here are the essential steps to remember when making a family health insurance claim:

Prompt Intimation:

Notify your insurance provider immediately when a medical event requiring a claim occurs. Timely intimation is especially crucial in emergency situations.

Understanding Your Policy:

Thoroughly understand the terms and conditions of your family health insurance policy. This includes knowing what is covered, exclusions, claim limits, and waiting periods.

Document Gathering:

Gather and maintain all relevant documents meticulously. These documents may include policy papers, the filled claim form, medical bills, prescriptions, diagnostic reports, and any other records related to the treatment.

Network Hospitals:

If your family health insurance policy has a network of empaneled hospitals, consider seeking treatment at these facilities. This can streamline the claim process, as the insurer often has a direct settlement arrangement with these hospitals.

Cashless Facility:

If your policy offers cashless hospitalization, you can avail treatment without making any payments at network hospitals. The insurer settles the medical bills directly with the hospital. Make sure you understand the cashless process and know which hospitals are part of the network.


If you plan to opt for cashless hospitalization, apply for pre-authorization. This involves obtaining approval from the insurer before undergoing planned treatments or surgeries. Pre-authorization is a critical step for a smooth cashless claim process.

Billing and Invoices:

Ensure that all bills and invoices are accurately documented and consistent with the treatment provided. Any discrepancies can lead to claim rejection.

Open Communication:

Maintain regular communication with the insurance provider throughout the claim process. Effective communication can help address any queries or provide any additional information required promptly.

Timely Submission:

Submit all the required documents within the stipulated timeframe. Delays in document submission can lead to claim rejection.

Policy Renewal:

Keep your family health insurance policy current by renewing it on time. An expired policy will not provide coverage, and any claims made during this period will be invalid.

Claim Reimbursement:

If your claim is a reimbursement claim (where you have already paid for the treatment), ensure you provide all original bills, invoices, and supporting documents for a successful claim.

Understand Exclusions:

Be aware of the exclusions in your policy. Certain treatments, pre-existing conditions, and specific medical procedures may not be covered. Understanding these exclusions can help prevent claim denials.

Medical Necessity:

Ensure that the treatment is medically necessary and adheres to the guidelines set by the insurance provider. Non-essential treatments may not be covered.

Record Maintenance:

Maintain records of all interactions and communications with the insurance company, including notes of phone calls, emails, and any claim reference numbers provided.

Claim Denials:

In the event of a claim denial, don’t lose hope. You have the right to appeal the denial and present additional information or clarify any discrepancies.

Stay Informed:

Stay updated with the latest changes in your policy. Insurance policies may undergo revisions, and staying informed can help you make better decisions regarding your claims.


Family health insurance is an invaluable asset for securing the well-being of your loved ones during medical emergencies. However, it’s crucial to acknowledge that variations in coverage exist among family members due to factors such as age, health conditions, and specific policy terms.

Understanding these variations and being well-versed in the nuances of your family health insurance policy is the key to optimizing your coverage.

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About the author

Sophia Britt

My name is Sophia and I live in the suburbs of Chicago. I offer real world experience to readers on how to save and smartly spend their money. Plus offer advice on organization, career, business, travel, health, home, education and life.

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