Health Insurance: Policy & Insurer Rating Framework

We follow a structured and transparent process to rate health insurance policies. The goal is to help customers compare plans on the basis of affordability, reliability, and coverage quality–not just premiums.

Every plan is evaluated across three dimensions:

• Premium Rating – based on the annual premium for a benchmark profile (30-year-old, ₹10L sum insured, Bengaluru).
• Insurer Rating – based on insurer strength and service quality, using published metrics such as claim settlement ratio, complaints, hospital network, gross written premium, TPA model, and digital presence.
• Features Rating – based on how comprehensive the policy’s benefits are, including room rent eligibility, co-payments, disease sub-limits, restoration, waiting periods, annual check-ups, AYUSH, consumables cover, and other features.

Each dimension is scored on a scale of 10. The final Policy Rating is calculated as follows:

Policy Rating = 0.1 × Premium Rating + 0.45 × Insurer Rating + 0.45 × Features Rating

The combined score is calculated on a 10-point scale. For display on our policy pages, which follow a 5-point format, the score is divided by 2. This keeps the presentation simple and comparable, while the underlying framework remains more granular.

Representation in “Best” or “Top” Listings

Our rating system is not only used to compare policies, but also to rank them objectively based on their overall scores. On pure numbers, this can mean that multiple products from the same insurer feature among the highest-ranked plans.

However, in line with our policy to keep rankings balanced and fair, we follow a one-slot-per-insurer rule for any “Best” or “Top” listing.

For example, in our system, both HDFC Optima Secure and HDFC Suraksha Platinum might make it to the top 5 list on an objective score basis. But in practice, HDFC will only be represented once in that list.

This ensures that readers see a diverse and fair mix of insurers and products, rather than one company dominating the rankings.

Important notes

• Standardised Inputs: All ratings are derived from measurable data points (e.g., claim settlement ratios, complaint volumes, policy wordings, filed premiums).
• Fixed Weightage: The formula uses fixed, pre-defined weights. There are no manual overrides to ensure consistency across all policies.
• Benchmark Profile: Premium comparisons are based on a single, declared profile (30-year-old, ₹10L SI, Bengaluru), preventing selective quoting.
• Ratings are based on publicly available information (filed policy wordings, insurer disclosures, and regulatory data). Actual benefits, terms, and premiums may vary depending on age, health, location, underwriting, and future product changes.
• The framework does not account for individual medical needs or personal suitability. Customers should carefully read policy brochures and consult licensed advisors before purchase.
• The scoring method is applied uniformly and is not influenced by commercial arrangements with insurers.
• Insurance is the subject matter of solicitation.

Rationale for the Weights

Each component in the Rating system has a different level of importance in determining the overall value of a plan. The weights are designed to balance coverage quality, insurer reliability, and affordability in a way that reflects how customers actually experience health insurance.

Features Rating – 45% Weight

• Why it matters: Features decide how much of your hospital bill is covered and how much you pay from your pocket. Room rent limits, co-payments, waiting periods, restoration benefits, and other terms directly affect financial protection.
• Wide variation across policies: Features differ significantly between products; a higher weight ensures meaningful differences in coverage are captured.
• Long-term consistency: Benefits generally remain stable year after year, unlike premiums which may fluctuate.

Insurer Rating – 45% Weight

• Why it matters: Even if benefits look strong on paper, the actual experience depends on the insurer’s ability to process claims smoothly. Claim settlement ratios, complaints, hospital networks, TPA models, and digital support all affect this.
• Hidden costs: Weak service can convert a covered claim into out-of-pocket expenses (delays, rejections, poor network coverage).
• Balanced emphasis: At 45%, insurer reliability is almost as important as benefits, but slightly lower since product features are more policy-specific.

Premium Rating – 10% Weight

• Affordability matters, but not most: Premiums affect initial cost, but they can change due to market cycles, discounts, or repricing. A cheap plan today may become expensive later, or may lack strong features.
• Small differentiator: Within our benchmark profile, premiums don’t vary as widely as features or insurer strength. A lower weight prevents price differences from overshadowing value.
• Avoids double-counting: Policies with stronger benefits and reliable insurers often cost more; a low weight ensures higher quality is not unfairly penalized.

Insurer Rating — How it’s being calculated

A policy is only as good as the company standing behind it. Our Insurer Rating tells you how reliable an insurer is when it comes to paying claims and supporting you through the process. Each insurer is scored on six real-world signals, combined into a 10-point score:

Insurer Rating = 0.30 × CSR + 0.25 × Complaints + 0.15 × GWP + 0.10 × Network + 0.10 × TPA + 0.10 × Online

(Each metric is converted to a 0–10 score before weighting.)

Why these weights?

Claim Settlement Ratio (30%)
What it tells you: How often valid claims are paid.

Why 30%: It’s the most direct indicator of “will my claim be accepted?”, so it gets the highest weight. We smooth it over a 3 year period to avoid one-year noise.

Volume of Complaints (25%)
What it tells you: How often customers face issues that escalate to the regulator/service desks.

Why 25%: A strong predictor of pain during claims and service. We size-adjust complaints (per claims/policies or per premium) and invert the score—fewer complaints → higher score.

Gross Written Premium (15%)
What it tells you: Scale and operating maturity.

Why 15%: Bigger isn’t always better, but scale correlates with stable processes, deeper hospital ties, and better claim infrastructure. Medium weight to reward stability without favoring giants excessively.

Network Hospitals (10%)
What it tells you: Cashless availability near you.

Why 10%: Network breadth reduces out-of-pocket risk and hassles. Useful, but secondary to whether claims are actually paid and serviced well.

TPA Model (10%)
What it tells you: Who runs claim servicing—in-house or external TPA(s).

Why 10%: Servicing model materially affects turnaround times and consistency. We score for proven, reliable setups (in-house with strong SLAs).

Online Presence (0.10)
What it tells you: How easily you can self-serve—buy/renew, raise claims, track status, download documents, get support.

Why 10%: Digital ease matters during stressful moments. It won’t rescue a weak claims engine, but it improves day-to-day experience.

With the weights set, the next step is to translate each raw metric into a 0–10 score. These scoring bands show what “good” or “poor” looks like on each parameter – whether it’s a very high claim settlement ratio, a broad hospital network, or a worrying volume of complaints.

Scoring Rules

1.1 Claim Settlement Ratio (CSR) — Scoring Bands

How we calculate CSR

Our Formula:
CSR = (Total number of claims settled ÷ Total number of claims available to settle) × 100

Where:
Total number of claims available to settle = (Claims Outstanding at the start of the year + Claims Reported during the year − Claims Closed without Payment − Claims Outstanding at the end of the year)

Why exclude “claims closed without payment”?
Because many of these are not true rejections—they’re cases where the policyholder never completed the process (e.g., withdrew the claim or didn’t submit documents). Including them would unfairly depress the ratio.

Why use a 3-year average?
CSR can fluctuate in any one year (e.g., due to pandemics or one-off spikes). Averaging across three years smooths this noise and gives a truer sense of consistency

Data source:
All figures are taken from the insurer’s official public disclosure Q4 NL-37 Claims Data Report (as mandated by IRDAI).

1.2 Network Hospitals — Scoring Bands

Why This Matters

• Cashless access = less stress: A broad hospital network reduces the chance of paying upfront and filing for reimbursement.
• Thresholds are practical, not arbitrary: Above ~12,000, the value of each extra hospital is marginal. But once the count drops below ~8,000, access issues become noticeable. Below 6,000, gaps are significant according to our analysis.

1.3 Volume of Complaints — Scoring Bands

Why this metric: Complaint load is a strong, real-world proxy for friction during claims and servicing.

• Normalization: Insurers report normalized values (complaints/1000 claims) so large players aren’t penalised for scale; In our model standalone health gets a 50% discount to correct for product-mix/reporting differences.
• Shape of penalties: Steeper drops after 20 reflect non-linear customer pain as escalation rates rise.

1.4 Gross Written Premium (GWP) — Scoring Bands

Why this metric: GWP reflects the scale and maturity of an insurer. Larger books usually mean stronger balance sheets, broader provider relationships, and more resilient claim systems.

• Plateau at 10k+: Once an insurer crosses ~₹10,000 crore in GWP, the extra size doesn’t dramatically change customer experience and the marginal benefit of more scale flattens out according to our analysis
• Penalties at lower scale: When GWP is very low, the insurer may have thinner operational capacity, less bargaining power with hospitals, and weaker buffers during claim spikes. This increases the risk of poor service or financial strain.

1.5 TPA (Third Party Administrator) — Scoring Bands

Why we measure this: The servicing model directly impacts turnaround times, accountability, and consistency during claims.

• Why in-house scores higher: When the insurer manages claims directly, there’s end-to-end control, fewer hand-offs, and stronger ownership of outcomes. This usually translates to faster resolution and better customer experience.
• Why external scores lower: External TPAs vary widely in quality. They introduce another layer in the process, which can mean delays, coordination gaps, or inconsistent service across insurers.

1.6 Online Presence — Scoring Bands

Why we measure this: A strong online presence makes it easier for customers to buy, renew, track claims, download policy documents, and find hospital networks without needing agent support.

• Why “Yes” scores 10: Insurers offering full digital self-service reduce friction and stress, especially during claims.
• Why “No” scores 2: Without these capabilities, customers must rely on phone/email support, which usually means slower turnaround times and higher frustration.

Features Rating — How It’s Calculated

The Features Rating evaluates how comprehensive a health insurance policy is in covering hospitalisation costs and reducing out-of-pocket expenses. Unlike premiums (which may fluctuate) or insurer-level metrics (which apply across all products), features are product-specific and have the most direct impact on what customers actually pay during a claim.

To make this assessment objective, we break down each policy into benefit categories — such as co-payments, room rent limits, restoration benefits, waiting periods, annual health check-ups, AYUSH coverage, consumables cover, and more. Each category is assigned a fixed weight, reflecting its relative importance to financial protection, and scored on a 0–10 scale using transparent rules.

The combined weighted score across all categories gives us the Features Rating, which contributes 45% of the overall Policy Rating. This ensures that policies with strong coverage features — not just low premiums or insurer size are recognised as providing better long-term value to customers.

Importantly, many newer products now come with a limited base design where most features are shifted into add-ons (e.g., consumables, unlimited restoration, or OPD). In such cases, we evaluate the policy with the add-ons included. The logic is simple: if a feature is available for purchase as part of the product, it must be reflected in the rating. This keeps comparisons fair and prevents policies from being over-penalised just because benefits are modularised.

Features Rating Formula
Each policy is scored on multiple benefit categories. Every category has:

• A raw score (0–10 scale, based on rules defined for co-pay, room rent, waiting periods, etc.)
• A weight (reflecting its importance, total = 100)

The Features Rating is the weighted average of all these scores:

Features Rating = ( Σ (Feature Score × Feature Weight) ) / 100

Important notes

1. Normalization: Each feature score is capped between 0 and 10.
2. Zero-weight feature (Maternity): By default, Maternity cover has weight = 0. Rationale: typical maternity features don’t add net value in general health policies — they inflate premiums, come with long waiting periods, and often force floater constructs. Keeping weight at 0 prevents artificially boosting policies that are costlier without proportional benefit.
3. Provision for maternity rankings: We retain the maternity row in the weights schema so that, when the goal is to rank maternity-focused policies, you can assign a non-zero weight and compute scores accordingly.

Why these weights?

Co-payment (10%)
What it tells you: Whether the insurer shares every claim in full or shifts a portion of the bill back to the customer.

Why 10%: Co-payments directly decide out-of-pocket costs. Even a modest 10–20% co-pay can wipe out the value of insurance for large claims. Because it has a high and recurring financial impact, it gets a strong weight.

Room Rent (14%)
What it tells you: The type of hospital room you’re entitled to without extra payment. From general ward to twin-sharing to single private rooms or higher.

Why 14%: Room rent is one of the most visible and impactful restrictions in health insurance. A low entitlement (like twin-sharing) can trigger proportionate deductions on the entire hospital bill, not just the room cost. This makes it a major driver of out-of-pocket expenses. Because of its outsized effect on actual claims, room rent carries the highest weight among individual feature categories.

Disease-wise Sub-limits (10%)
What it tells you: Whether the insurer caps reimbursement for specific treatments like cataract surgery, hernia, or knee replacement.

Why 10%: Sub-limits are a hidden cost driver. Even if the overall sum insured is large, disease-wise caps can force significant out-of-pocket payments for common procedures. Because these limits directly undermine the value of the cover, they carry a high weight in our framework.

Restoration (8%)
What it tells you: Whether the policy restores your sum insured after it’s been used up, and under what conditions (e.g., partial, full, unlimited, or only for unrelated illnesses).

Why 8%: Restoration is a high-utility feature, especially in years with multiple hospitalisations. It prevents customers from running out of cover. However, it usually kicks in only after some triggers (like full exhaustion or different illness), so while valuable, it’s not as fundamental as room rent or co-pay. That’s why it carries a moderately high weight.

No-Claim Bonus (10%)
What it tells you: Whether your sum insured increases when you don’t make a claim, and how that bonus is structured (simple %, carry-forward, super bonus, or loyalty benefit).

Why 10%: The No-Claim Bonus is a powerful long-term value driver. Over a few claim-free years, it can significantly boost coverage without raising premiums. Policies that claw back the bonus after a claim, or offer only token increments, dilute the benefit. Because NCB meaningfully strengthens protection over time, it is given a high weight.

Initial 30-day Waiting Period (3%)
What it tells you: Whether the policy imposes the standard initial waiting period (typically 30 days from purchase) before most illnesses are covered, and if there are any exceptions.

Why 3%: The initial waiting period is a short-term limitation. It only affects claims made in the first month after purchase. While important to note, it has little long-term impact compared to features like room rent or PED waiting periods. That’s why it carries a low weight in the framework.

Specific Disease Waiting Period (4%)
What it tells you: The fixed time (usually 2–4 years) before certain common conditions like hernia, cataract, or joint replacement are covered.

Why 4%: These exclusions are standard across most policies, so they don’t create major differentiation. In fact, the clause protects customers too — without it, insurers may be tempted to deny claims citing “non-disclosure” of pre-existing issues. Since it’s both a standard feature and a safeguard, it carries a low-to-moderate weight in the framework.

Pre-existing Disease (PED) Waiting Period (6%)
What it tells you: The length of time before claims for conditions you already have at the time of purchase (e.g., diabetes, hypertension) become payable.

Why 6%: PED waiting is one of the most material exclusions in health insurance, since many customers buy cover later in life with existing conditions. A shorter PED wait directly increases the policy’s usefulness. At the same time, some waiting is necessary to prevent misuse. Because it’s a key differentiator but also a standard clause, it carries a moderately high weight.

Annual Health Check-ups (7%)
What it tells you: Whether the policy includes preventive health check-ups, how often they are provided, and whether conditions (like no-claim years) apply.

Why 7%: Regular check-ups are a valuable long-term benefit — they encourage preventive care, help track lifestyle diseases early, and provide tangible value even in claim-free years. However, they don’t affect financial protection during hospitalisation as directly as co-pay or room rent, so the weight is moderate rather than high.

AYUSH Coverage (3%)
What it tells you: Whether the policy covers alternative systems of medicine — Ayurveda, Yoga, Unani, Siddha, and Homeopathy — and if any sub-limits or restrictions apply.

Why 3%: While AYUSH gives flexibility, in practice claims are harder to process. Hospitalisation is often difficult to establish under AYUSH protocols, and many payouts happen only on a reimbursement basis, not cashless. This limits the real-world usability of the benefit. Because of this, AYUSH is kept at a low weight, recognising it as a “nice-to-have” but not a core protection feature.

Domiciliary Hospitalisation (5%)
What it tells you: Whether the policy covers treatment at home when hospitalisation isn’t possible — either because the patient cannot be moved, or because no hospital bed is available.

Why 5%: This benefit has practical value in limited scenarios, like during pandemics or for patients with mobility issues. However, it’s not commonly used, and many policies attach sublimits or documentation hurdles that restrict claims. It’s meaningful enough to warrant inclusion, but carries only a moderate weight since it’s less central than co-pay, room rent, or waiting periods.

Daycare Procedures (5%)
What it tells you: Whether the policy covers procedures that require less than 24 hours of hospitalisation, such as cataract surgery, dialysis, and chemotherapy.

Why 5%: Coverage for daycare procedures is now mandatory under IRDAI guidelines, so all modern health insurance products include it. However, some older policies in the market either don’t provide daycare coverage or restrict it to a limited list of procedures. We keep a small weight here mainly for historical accuracy and to differentiate modern, compliant designs from outdated ones.

Maternity Cover (0%)
What it tells you: Whether the policy provides maternity benefits — usually covering delivery costs, newborn care, and related hospitalisation expenses, often with long waiting periods and sub-limits.

Why 0%: For most customers, maternity cover is a net negative in regular health policies:

• It typically comes with 3–4 year waiting periods, making it unusable in the near term.
• It often forces a floater policy design, even for people who would prefer individual covers.
• Premiums are inflated because maternity is bundled, even when the customer has no need for it.

Because of these factors, maternity is set at zero weight so it doesn’t distort policy ratings in favour of features that don’t add proportional value.

Provision for maternity rankings: We retain maternity in the framework with a defined row so that, if we specifically compare maternity-focused policies, a positive weight can be assigned. In those cases, other feature weights are rebalanced to keep the total at 100.

OPD Benefits (3%)
What it tells you: Whether the policy covers outpatient expenses — like doctor consultations, diagnostics, and medicines — which don’t require hospitalisation.

Why 3%: OPD benefits are useful for routine medical costs, but they don’t protect against the large, unpredictable expenses that health insurance is primarily meant for. In many cases, OPD cover also comes with tight sub-limits and pushes premiums up disproportionately. That’s why OPD gets a small weight — it’s a nice-to-have, but not a core driver of financial protection.

Wellness & Fitness Benefits (3%)
What it tells you: Whether the policy includes wellness-oriented add-ons such as gym memberships, fitness programs, step-tracking rewards, or discounts linked to maintaining an active lifestyle.

Why 3%: These riders can encourage preventive health and fitness, but they don’t materially improve financial protection against hospitalisation costs — the core purpose of health insurance. They also tend to be marketing-led differentiators with variable real-world uptake. That’s why they carry a low weight: recognised as a plus for wellness-focused customers, but not central to policy value.

Consumables Cover (5%)
What it tells you: Whether the policy covers non-medical items used during hospitalisation — such as gloves, masks, syringes, PPE kits, and other consumables that are typically billed but often excluded by insurers.

Why 5%: Consumables can make up a substantial part of a hospital bill (especially after COVID-19, where PPE costs ran high). Policies that cover them reduce unpleasant surprises for customers. However, since not all hospitalisations generate high consumables costs, this feature gets a moderate weight — meaningful, but not as critical as co-pay or room rent.

Unique Features (4%)
What it tells you: Whether the policy includes innovative benefits that are not yet standard in the market.

Why 4%: Unique features showcase early product innovation and can provide meaningful advantages to customers. For example, Lock the Clock allows your entry age to be fixed at the time of purchase, preventing steep premium jumps later.

These features are given a modest weight — enough to recognise innovation, but not so high that they overshadow core protections like room rent or co-pay. As the market evolves and more policies adopt a particular feature, it may be promoted into the main features list with its own weight.

Scoring Rules
With the weights defined, the next step is to translate each feature into a 0–10 score. These scoring bands make the framework transparent by showing what counts as strong coverage versus weak coverage on each parameter — whether it’s having no co-payment, entitlement to a private room, shorter waiting periods, or broader coverage for consumables.

This ensures that every product is judged by the same yardstick, and that the final Features Rating reflects not just whether a benefit exists, but how well it is designed.

(a) Co-payment

Why it matters: Co-payments directly impact every claim. Even a small mandatory share (10–20%) can run into lakhs for high-value hospitalisations, making this one of the most customer-visible features.

• Why “No co-payment” = 10: Full coverage ensures that the insurer, not the customer, bears the entire financial burden.
• Why partial scores: Conditional co-pays (non-network, age-based) are less damaging but still create friction.
• Why mandatory = 1: Compulsory co-pays in all cases significantly reduce the protective value of the policy.

(b) Room Rent

(Penalize up to 5 points if ICU restrictions apply; minimum score = 1)

Why it matters: Room rent limits are one of the most visible and impactful restrictions in health insurance. They don’t just affect the cost of the room — they trigger proportionate deductions across the entire hospital bill if you choose a higher category.

• Why “Any room” = 10: Policies that allow free choice of room (including private rooms and ICU without caps) provide full flexibility and eliminate hidden deductions.
• Why partial scores: Entitlements like twin-sharing or capped private rooms restrict choice and expose customers to proportionate billing cuts.
• Why penalise ICU restrictions: ICU is a critical care area where charges are unavoidable. If a policy limits ICU rent, it severely undermines protection, so penalties apply.

(c) Daycare Procedures

Why it matters: Advances in medical technology mean many procedures (like cataract, dialysis, chemotherapy) no longer require 24-hour hospitalisation. Policies that exclude or restrict daycare cover leave customers exposed for these common treatments.

• Why “Yes (full)” = 10: Full daycare coverage ensures all eligible short-stay procedures are covered, aligning with IRDAI’s mandate for modern policies.
• Why partial scores: Older products or restrictive designs may cover only a limited list, which reduces usefulness.
• Why “No” = 1: A policy without daycare coverage is outdated and creates significant gaps in protection (although these policies are mostly discontinued)

(d) Initial 30-day Waiting Period

(Deduct 2 points if certain conditions exceed 30 days)

Why it matters: Almost all health policies impose a short waiting period (usually 30 days) before most illnesses are covered, except accidents. While this is standard and temporary, it affects claims made in the first month of the policy.

• Why “No” = 10: A policy that waives the initial waiting period provides immediate protection from day one, which is ideal.
• Why “Yes” = 5: A standard 30-day wait is acceptable, but it still leaves a short window of exposure.
• Why deduction applies: Some policies extend this period beyond 30 days for certain conditions, which unfairly reduces early coverage.

(e) Specific Disease Waiting Period

Why it matters: This clause applies to a list of common surgeries (like cataract, hernia, joint replacement) that insurers put under waiting periods. While it’s a standard feature across most products, it can still delay coverage for high-incidence treatments.

• Why “No waiting” = 10: Immediate coverage removes barriers and maximises usability.
• Why shorter waits = higher scores: Policies with 1–2 year waits are customer-friendly, ensuring faster access to benefits.
• Why 3 years = 2: A long delay reduces usefulness for some of the most common medical procedures.
• Why standardisation is good: This clause also protects customers — without it, insurers might reject claims citing “non-disclosure” of past conditions.

(f) Pre-existing Disease (PED) Waiting Period

*Applies only to older products filed before IRDAI’s 2024 regulations. Current rules cap PED waiting periods at 3 years maximum for all new health policies.

Why it matters: The PED clause decides when claims for conditions you already have — like diabetes, hypertension, or asthma become payable. Since many buyers enter the health insurance market with pre-existing illnesses, this waiting period is one of the most material exclusions in any policy.

How to interpret the bands:

• 30 days / 1 day (10 points): Near-instant coverage is the gold standard, seen only in a handful of innovative products.
• 1–2 years (9–8 points): Highly customer-friendly. These policies balance insurer risk while giving buyers meaningful access within a short timeframe.
• 3 years (5 points): The new regulatory maximum. It’s compliant but slower access, and represents the lowest score allowed under IRDAI’s current rules.
• 4 years (2 points): Now considered legacy. While you may still see brochures mentioning 4 years, these belong to older products and are not permitted in actively sold policies. They score low because such a long delay makes cover far less useful.

(g) Domiciliary Hospitalisation

Why it matters: Domiciliary hospitalisation applies when treatment is taken at home instead of a hospital either because the patient cannot be moved or because hospital beds are unavailable. It also sometimes includes home-care treatments supervised by a doctor.

• Why higher scores = broader coverage: Policies that cover both domiciliary and home care without restrictive sublimits provide the strongest protection in real-world scenarios like pandemics or chronic illness management.
• Why partial scores: Many insurers impose caps, specific conditions, or sublimits, which limit the usability of this feature.
• Why “None” = 1: A policy that excludes domiciliary/homecare entirely creates a gap, especially in emergencies where hospitalisation is impractical.

(h) AYUSH Treatment

Why it matters: AYUSH (Ayurveda, Yoga, Unani, Siddha, Homeopathy) treatment is recognised under health insurance, but its usability is mixed. Many claims are processed only on a reimbursement basis, and proving hospitalisation can be harder than for allopathic treatment.

• Why “Without sublimits” = 10: Full cover ensures customers who prefer AYUSH systems aren’t penalised.
• Why partial scores: Sublimits or caps reduce the scope of coverage and often restrict payouts.
• Why “None” = 1: Policies that exclude AYUSH deny customers access to a regulator-recognised form of treatment.

(i) No-Claim Bonus

(Adjustments: −1 if there’s a clawback after a claim; +2 if there’s a loyalty/super bonus that grows faster over time)

Why it matters: The No-Claim Bonus (NCB) rewards claim-free years by increasing the sum insured without raising premiums. Over time, this can significantly enhance coverage value, especially for families with few claims.

• Why higher = better: Bigger and more flexible NCB structures (like carry-forward of unutilized amounts) directly strengthen protection.
• Why partial scores: Small increments or clawback rules weaken the benefit.
• Why “None” = 0: Policies without any NCB lose out on one of the most effective long-term enhancers of coverage.

(j) Restoration Benefit

(Deductions: −4 if only after complete exhaustion; −2 if only for different illnesses; −1 if a cool-off period applies)

Why it matters: Restoration benefit automatically refills your sum insured after it’s used up. This matters most in years with multiple hospitalisations or high-value claims.

• Why unlimited = 10: Full, no-conditions restoration gives maximum financial security.
• Why partial scores: Single-use or conditional restorations (e.g., only for different illnesses) reduce practical usability.
• Why “None” = 1: Without restoration, once the cover is used up, you’re exposed until renewal.
• Why deductions: Some restoration features look attractive on paper but come with conditions that weaken their value. We apply deductions to reflect this:
  • −4: Only after complete exhaustion
    Restoration kicks in only if the full sum insured is used up — harder to access, reduces real utility.
  • −2: Only for different illnesses
    Doesn’t apply to repeat claims for the same condition (e.g., multiple cancer treatments).
• −1: Cool-off period
  A time gap (e.g., 45–60 days) is required before restoration can be reused, adding restrictions.

(k) Annual Health Check-ups

(Deduct −2 if the check-up benefit is conditional on a claim-free year)

Why it matters: Annual health check-ups encourage preventive care and give customers tangible value even when no claims are made. They help in detecting lifestyle diseases early and make the policy feel more rewarding.

• Why every year = 10: Regular yearly tests ensure consistent monitoring and add the most customer value.
• Why once in 2 years = 5: Better than none, but less effective for preventive health.
• Why “No” = 1: A policy without any check-up benefit misses an easy way to support long-term health management.
• Why deduction applies: Some insurers allow check-ups only if no claim is made — this reduces usability and undermines the preventive intent.

(l) Disease-wise Sub-limits

Why it matters: Sub-limits cap payouts for specific treatments (like cataract surgery, knee replacement, or cardiac procedures). They can create hidden out-of-pocket costs even when you have adequate sum insured.

• Why “No sub-limits” = 10: Full freedom ensures the policy pays as per actual hospital bill, without arbitrary caps.
• Why partial scores: Restricting a few common surgeries is less damaging than broad caps across multiple conditions, but still erodes value.
• Why “More than 5 conditions” = 1: Widespread sub-limits hollow out the policy and defeat the purpose of comprehensive coverage.

(m) OPD Benefits

Why it matters: Outpatient Department (OPD) benefits cover everyday medical costs like consultations, diagnostics, and medicines — expenses that don’t require hospitalisation. While these can add convenience, they don’t protect against the large, unpredictable costs health insurance is meant for.

• Why “OPD” = 10: Comprehensive OPD cover, with reasonable limits and broad scope, helps customers manage frequent, smaller expenses, even if the net value may not be substantial
• Why “None/Poor” = 1: Policies without OPD leave customers paying out of pocket for routine healthcare.

(n) Consumables Cover

Why it matters: Consumables include items like gloves, syringes, masks, PPE kits, and other non-medical supplies billed during hospitalisation. These costs became especially visible during COVID-19, when PPE alone often ran into thousands per admission.

• Why “Yes” = 10: Policies that include consumables cover remove a common source of out-of-pocket expense and make claims more predictable.
• Why “No” = 1: Excluding consumables means customers must bear these recurring costs directly, which can add up significantly during long or multiple hospital stays.

(o) Wellness & Fitness Benefits (formerly Befit Rider Types)

Why it matters: Some modern health policies bundle in wellness or fitness benefits — like gym memberships, yoga classes, nutrition programs, or wellness apps. These are positioned as add-ons to encourage healthier lifestyles.

• Why “Yes” = 10: Policies that include structured wellness benefits provide tangible value beyond hospitalisation, supporting preventive health.
• Why “No” = 1: Most policies don’t offer them, and their absence doesn’t reduce core protection, but it does mean customers miss out on extra perks.

(q) Unique Features

Why it matters: Unique features are innovations insurers introduce that aren’t yet standard in the market. They add incremental or sometimes significant value on top of the core benefits.

• Why points vary: Each feature is scored based on usefulness and real-world impact. For example, Get Back Your Premiums (return of premiums) earns more points than Unlimited Claim, which is incremental.
• Multiple features rule: If a policy includes several unique features, their scores are added together. However, the maximum contribution is capped at 10, so no policy can gain outsized advantage purely from stacking innovations.
• Dynamic treatment: Once a unique feature becomes common across 5+ products, it is moved into the main features list with its own fixed weight, and all weights are rebalanced to keep the framework fair.

Premium Rating

Benchmark: 30M • Individual • ₹10L SI • 560076 • annual incl. GST)

Scoring buckets

Scope & inputs (normalized)

• Variant: Base/standard product; optional add-ons OFF; mandatory/bundled add-ons included.
• Health: Healthy life (no loadings)
• Channel: Public/D2C quote (web/app). No promo codes or time-bound offers.
• Mode: Annual payment
• Taxes: Premium includes GST.
• Geo: Use 560076 (Bengaluru).

What if premium data isn’t available?

Our benchmark ratings rely on publicly reproducible D2C premiums (for a 2-adult, ₹10 lakh floater, Bengaluru).

Sometimes insurers don’t display these premiums online. In such cases, we calculate a provisional Policy Rating by assigning the Premium Score = 3 (essentially removing its influence).

• These plans are clearly marked as “Premium unavailable” on our pages.
• Once the benchmark D2C premium becomes available, we update the Policy Rating using the standard formula (with Premium contributing its 10%).
• Until then, provisional ratings are considered incomplete and are excluded from Best/Top listings

Important notes

• Top-up / Super top-up:
  These are priced and rated separately (different product type). You’ll see them in the Top-up section, not mixed with base health plans.
• Sometimes a plan forces you away from our benchmark choice. When that happens, we mark the Premium Rating as Expensive (Score 3) so you know the comparison isn’t apples-to-apples.
• ₹10L individual not offered:
  The plan doesn’t sell an individual ₹10L option at all (you may be pushed to a higher SI). Expensive by design – Score 3. We may display the nearest available SI for context, but it doesn’t change the score.
• ₹10L only as a floater (no individual option):
  You’re forced into a floater structure even if you want just one person covered. Result: Expensive by design – Score 3