Family Health Cover
Example Health Insurance Ltd · sample policy wording
Family Health Cover is a health insurance policy that pays hospital bills up to a yearly limit. This is a sample policy written for CheckTOS to show how a read of an insurance policy works; Example Health Insurance Ltd is not a real insurer.
Short numbered clauses in plain sentences, with a few defined terms and one proportion rule that takes a second read.
Anything you had in the 36 months before you bought the policy is not covered for its first three years.
- You pay 10% of every claim yourself, and 20% from the age of 61.Your money
- Choose a room above 1% of the Sum Insured a day, and the whole claim shrinks in proportion.Your money
- Illness in the first 30 days, and cataract, hernia and joint surgery in the first two years, are not covered.Your cover
- Emergencies must be reported within 24 hours, and reimbursement papers sent within 30 days of discharge.Your claim
- Example Health can cancel only for established fraud, with 15 days’ notice.Your cover
What the policy covers
Example Health pays reasonable hospital charges up to the Sum Insured each policy year. A hospital stay has to last at least 24 hours, except for day-care procedures.
"We will pay the reasonable and customary charges for hospitalisation of an insured person, up to the Sum Insured shown in the Schedule, for each policy year."Section 2 · What we cover
"Hospitalisation means admission to a hospital for at least 24 consecutive hours."Section 1 · Definitions
The yearly limit is in the Schedule, which this sample does not include.
What it excludes
The policy excludes conditions from the 36 months before it started, for its first 36 months. Cosmetic treatment is out unless an accident caused the need, and treatment abroad is out entirely.
"We will not pay for any claim arising from a pre-existing disease until 36 months of continuous coverage have passed."Section 4 · Exclusions
"Treatment outside India is not covered."Section 4 · Exclusions
"Continuous" coverage means a missed renewal restarts the clock.
Waiting periods and conditions
Illness diagnosed in the first 30 days is not covered unless an accident caused it. Cataract, hernia and joint replacement wait two years.
"Any illness first diagnosed within 30 days of the policy start date is not covered, except claims arising from an accident."Section 5 · Waiting periods
"Cataract, hernia and joint replacement surgery are covered only after 24 months of continuous coverage."Section 5 · Waiting periods
Costs you carry
You pay 10% of every admissible claim, or 20% if you are 61 or older when admitted. The policy caps room rent at 1% of the Sum Insured a day, and a pricier room reduces the rest of the claim in the same ratio.
"Each admissible claim is subject to a co-payment of 10%, which the insured person must pay."Section 6 · Co-payment
"If you choose a room above this limit, all associated expenses will be paid in the same proportion as the eligible room rent bears to the actual room rent."Section 3 · Room rent
The proportion rule applies to "all associated expenses", so a room twice the limit halves the payout on the whole bill.
How to make a claim
Tell Example Health 48 hours before a planned stay, or within 24 hours of an emergency admission. Send reimbursement papers within 30 days of discharge. Cashless treatment works only at network hospitals.
"For an emergency, you must tell us within 24 hours of admission."Section 7 · Making a claim
"Reimbursement claims must be submitted with all documents within 30 days of discharge."Section 7 · Making a claim
The policy does not say what happens to a claim filed after 30 days.
Renewal, cancellation and changes
The policy renews for life if you pay within the 30-day grace period. Example Health can raise the premium at renewal with the regulator’s approval. You have 30 days after receiving the policy to cancel for a near-full refund.
"This policy is renewable for life, provided the premium is paid before the end of the grace period of 30 days."Section 8 · Renewal
"We may cancel this policy only on grounds of established fraud, by giving 15 days’ written notice."Section 10 · Cancellation
Cancelling after the free-look period refunds less, on the short-period scale in the Schedule.
Disputes and governing law
Complaints go to Example Health first. After 15 days without a satisfactory answer, you can go to the Insurance Ombudsman. Indian law applies, and the courts of Mumbai hear disputes.
"If you are not satisfied with our response within 15 days, you may approach the Insurance Ombudsman."Section 11 · Complaints
"This policy is governed by the laws of India, and any dispute is subject to the jurisdiction of the courts of Mumbai."Section 12 · Law and jurisdiction
Structure summary
We quote each item below and name its place in the documents.
1 found
1 found
1 found
2 found
1 found
0 found
How to reach them
Taken from the documents and sorted by what you need.
Caveats
This breakdown explains what a sample insurance policy says. The document and Example Health Insurance Ltd are fictional, written for CheckTOS to show how a read works. It is not legal advice, does not assess whether any clause would hold up, and does not judge anyone. Every quote is word for word from the sample document. Read on 30 September 2026.
Read the fine print on anything you sign.
CheckTOS is a downloadable skill. Point it at any terms of service and get this same plain-language read inside your own Claude, on your own tokens.
Download Skill ↓