Rajkumar Anguluri·Software Engineer · Founder, Artha Engine·Last reviewed 24 April 2026·Methodology
Independent decision-support tool. Artha Engine is not a financial services provider, does not sell loans or insurance, and has no commission relationships with banks or insurers.
Policy Quality Checker India - Audit Your Health Insurance
Audit an existing Indian health insurance policy for hidden claim traps: room-rent caps, co-pay, deductibles, waiting periods, exclusions, network, renewability, and claim-shock leakage.
Policy audit
Enter what your Customer Information Sheet or policy schedule says. Unknown fields can stay at conservative defaults until you verify them.
Save & share this scenario
Bookmark these inputs, copy a link, or send the result to someone.
Policy quality score
68.0%
Risky policy structure
Educational policy audit based on self-reported clauses. Verify against the Customer Information Sheet and policy wording.
The policy ceiling is below 60% of the recommended base-plus-top-up stack for this city and family profile.
Do not cancel this policy first. Secure replacement or enhancement terms before renewal.
Quality score
68.0%
Recommended total cover
₹78L
Cover ratio
0.13
Your share in claim shock
₹0
Insurer pays in claim shock
₹10L
Renewal posture
replace carefully
Score by dimension
Breakdown
- Cover adequacy1.0%5.0%
- Claim deductions25.0%100.0%
- Waiting and continuity9.0%60.0%
- Coverage breadth16.0%80.0%
- Servicing and compliance17.0%85.0%
Benchmarks
Claim bill vs insurer payout
You
₹10L
Benchmark
₹10L
Shows how much of the modeled bill does not reach insurer payout.
Gap to solid score
+2.9%You
₹68
Benchmark
₹70
70+ is the threshold for a solid policy structure.
What moves the result most
Holding everything else fixed, here is how the headline shifts when each input swings by a typical range.
Sum insured is materially low
The policy ceiling is below 60% of the recommended base-plus-top-up stack for this city and family profile. Increase base cover or add a super top-up before relying on this policy.
PED waiting period is still material
Claims connected to pre-existing diseases may not be payable until the waiting period is served. Preserve continuity and portability credit; do not create an uninsured gap.
Claim-shock estimate
On a modeled 10L hospitalization, this policy leaves about 0L to you after caps, deductible, co-pay, sublimits, and consumables assumptions.
You pay
₹0
How we reached this answer
Every rule that fired against your inputs, in evaluation order.
Sum insured is materially low
criticalThe policy ceiling is below 60% of the recommended base-plus-top-up stack for this city and family profile. Increase base cover or add a super top-up before relying on this policy.
Source · Policy clause audit
PED waiting period is still material
warningClaims connected to pre-existing diseases may not be payable until the waiting period is served. Preserve continuity and portability credit; do not create an uninsured gap.
Source · Policy clause audit
Next best actions
The result hints at what to look at next. Each link carries your current numbers so you never re-enter them.
Size the right total cover
The quality score is constrained by a low sum insured. First find the correct cover ceiling.
Compare base vs super top-up
A top-up can raise the claim ceiling cheaply once the base policy is stable.
Add insurer claim-settlement context
The score is more complete when insurer servicing data is entered.
Like this calculation?
Save it to your account so you can revisit it anytime, or share the scenario with someone who needs to see it.
At a glance
- What it does
- Scores a self-reported health policy across cover adequacy, claim deductions, waiting periods, coverage breadth, and servicing/compliance signals.
- Hidden traps checked
- Room-rent and ICU caps, co-pay, zone co-pay, deductible, disease sublimits, consumables, PED waits, maternity/newborn gaps, modern treatments, and protected-category cover.
- Claim shock
- Models a large hospitalization bill and estimates what leaks to you after cap, deductible, co-pay, sublimit, and consumables assumptions.
- Best used for
- Before renewal, portability, or buying a recommended policy from an agent. It checks policy structure, not insurer product names.
How It Works
This is the drill-down layer. The flagship flow leads with a recommendation, and this page lets you inspect the underlying model.
- Total score = cover adequacy (20) + claim deductions (25) + waiting and continuity (15) + coverage breadth (20) + servicing and compliance (20).
- Cover adequacy reuses Artha health-cover benchmarks: recommended base cover plus a city-adjusted super top-up layer.
- Claim shock = modeled bill - estimated insurer payout after room-rent cap, deductible, co-pay, sublimits, and consumables leakage.
Assumptions
The recommendation stays blunt, but the assumptions remain visible.
- Inputs are self-reported from the Customer Information Sheet, policy schedule, and wording. The tool is educational and not insurance advice.
- Clause weights reflect Indian retail health-policy market practice and Artha editorial judgment; regulatory items are cited to IRDAI at page level.
- The checker does not recommend named insurers or products. It flags structural risks and routes users to the next decision tool.
FAQ
The follow-up questions people usually ask after the main recommendation is already clear.
Can this tell me whether a named policy is good?
Yes, if you enter the policy's actual clauses. The checker intentionally avoids product-name scoring because brochures change and named recommendations can become stale. The policy wording matters more than the label.
Does age or gender change the policy-quality score?
Yes. Senior-citizen status, renewal premium increases, maternity/newborn needs, chronic conditions, and protected-category coverage all affect the result. Gender itself is not penalized; the tool uses it to surface relevant clauses.
Why does a high sum insured still get a weak score?
A large cover can still leak money if room rent is capped, co-pay is high, disease sublimits apply, PED waiting is long, or consumables are excluded. The score separates cover size from claim usability.
Should I replace a risky policy immediately?
Not automatically. Never cancel existing health insurance until replacement cover is issued and you understand waiting-period, portability, and continuity consequences. The output says whether to renew, enhance, or replace carefully.
Sources & references
Every formula and assumption above is grounded in these authoritative sources.
Related tools & decisions
Keep going from here — each link carries the same cluster context.
What to do next
Comparison pages
Base vs Super Top-Up: What's the Cheapest Way to Reach ₹40L Health Cover?
Single high base policy or smaller base + super top-up stack — which is cheaper for the same total cover? Free Indian calculator with cumulative premium savings.
Floater vs Individual Health Insurance: Which Is Cheaper for Your Family?
One shared floater pool or separate individual policies per member — which costs less AND protects each member fully? Free Indian calculator for family health cover with coverage-parity comparison.
Employer Health Insurance vs Personal: Do You Need Both?
You already have employer group health cover. Do you still need personal insurance? Free Indian calculator that models total cost to life expectancy — not just this year's premium.
Related guides
Long-form explainers that put the math behind this tool in context.
Calculations and decision frameworks, not personalised financial advice. The numbers on this page are based on the inputs you supplied and the regulatory rules in effect when this page was last reviewed. They are not a recommendation to buy, sell, hold, port, or surrender any specific financial product. Consult a SEBI-registered investment advisor, a qualified tax professional, or a licensed insurance broker before acting on a financial decision involving your money.
Artha Engine is an educational decision-support website. We do not offer loans, sell insurance, distribute mutual funds, provide regulated investment advice, collect loan applications, or receive commissions from banks, insurers, AMCs, brokers, or other financial providers. References to RBI, SEBI, IRDAI, Income Tax Department, or other authorities are source citations only. Artha Engine is not affiliated with, endorsed by, or sponsored by any government authority, regulator, bank, insurer, AMC, or broker. Artha Engine does not charge users fees for using calculators, comparison tools, articles, or financial health scoring. Mailing address: India.
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