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What Is Health Insurance Eligibility Criteria?

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By Apollo 24|7, Published on - 13 June 2024, Updated on - 13 November 2024

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Health insurance is one of the most important factors to consider when it comes to the financial planning of an individual or a family’s health needs. Discussing the health insurance qualification requirements for various health insurance plans is crucial to ensure you and your loved ones are well protected. This guide will explain the general health insurance eligibility criteria. We will also know about the criteria-specific requirements for various types of health insurance and how to decide whether you are eligible for coverage.
 

General Eligibility Criteria for Health Insurance

The requirements for health insurance depend on the type of insurance policy and the company that offers it. However, some general requirements and eligibility for health insurance plans are:

Criteria

Description

Age

Most plans have a minimum and maximum age limit. Typically, individuals aged 18 to 65 are eligible. Some plans offer coverage for children from 91 days onwards.

Residency

Must be a resident of India.

Income

Some plans, especially government-sponsored ones, have eligibility requirements for income.

Employment Status

Employer-sponsored plans require you to be an employee of the company offering the plan.

Health Status

Pre-existing conditions may affect eligibility or the cost of premiums.

Eligibility for Different Types of Health Insurance Plans

1. Employer-Sponsored Health Insurance

Employer-sponsored health insurance is one of the most common types of health insurance. Here’s what you need to know: 

Criteria

Description

Employment

Must be a full-time or part-time employee (depending on company policy).

Waiting Period

Some employers have a waiting period (e.g., 30-90 days) before coverage begins.

Dependents

Spouses, children, and sometimes parents may be eligible for coverage under the employee's plan.

2. Individual Health Insurance

Individual health insurance is purchased directly by individuals rather than through an employer. The individual health insurance criteria include:

Criteria

Description

Age

Varies by plan but generally open to all ages, with specific plans for children and senior citizens.

Residency

Must reside in India.

Income

May affect eligibility for certain types of plans, especially those with subsidies.

Health Status

Pre-existing conditions may influence the terms of coverage or waiting periods.

3. Health Insurance for Families

Family health insurance plans are designed to provide coverage for all family members under a single policy. Here's what you need to know about health insurance for families eligibility: 

Criteria

Description

Primary Applicant

Typically, the primary applicant must meet the criteria for individual health insurance.

Dependents

Spouses, children (biological, adopted, or stepchildren), and sometimes other dependents like parents.

Age Limits for Children

Usually covers children up to age 25, though this can vary by plan.

Residency

All family members must reside in India.

Special Considerations in Health Insurance

When purchasing health insurance in India, several special considerations can significantly impact your health insurance coverage eligibility and benefits. These include:

  • Pre-existing Conditions: The majority of health insurance policies in India come with a waiting period for pre-existing conditions, and they can be anywhere from 2 years to 4 years. However, after the waiting period, the insurers cannot decline to offer insurance coverage to the clients for pre-existing conditions.
  • Waiting Periods: In most health insurance plans, there are waiting periods that may apply during which some of the benefits cannot be claimed. This includes initial waiting periods (typically 30 days), waiting periods for specific diseases (1-2 years), and pre-existing conditions (2-4 years).
  • Portability: Health insurance portability allows the policyholder to transfer his/her health insurance policy from one insurer to another without facing the implications of a change in the insurer and without losing the continuity benefits related to waiting periods and pre-existing disease conditions.
  • No-claim Bonus: Most health insurance policies contain a no-claim bonus, which is an increase in the sum assured or a reduction in the premiums for each year in which no claim is made.

So, it is important to know the basic health insurance eligibility requirements to make the right choice for yourself and your family. Whether you are focusing on personal, company-provided, or government health insurance, it is important to know the details and eligibility so everyone can be properly insured. For more precise information about the health insurance criteria and eligibility, it is always recommended that you connect with the insurance company directly.

Know More Here 

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Frequently Asked Questions

Can senior citizens above 65 years get health insurance in India?

What are the eligibility criteria to get health insurance plans for newborns in India?

What happens if I move to a different state in India? Will my health insurance still be valid?

Is there an age limit for dependents on a family health insurance plan?

What documents are required to apply for a health insurance policy?

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