What Arogya Sanjeevani standard health insurance covers
The Arogya Sanjeevani policy is a standard health insurance plan designed by IRDAI. Every insurer follows the exact same rules. Read how the mandatory 5 percent copay works, what the strict room rent limits are, and which treatments are permanently excluded from coverage.
By Qrates research desk · 2026-10-27
The Arogya Sanjeevani policy covers hospital stays, day care procedures, and AYUSH treatments with identical rules across all insurance companies. Every claim includes a mandatory 5 percent copay, and hospital room rent is strictly capped at 2 percent of your sum insured.
Quick answer: What Arogya Sanjeevani covers
The Arogya Sanjeevani policy covers hospital stays, day care procedures, AYUSH treatments, and medical expenses before and after hospitalisation. It is a standard health insurance policy irdai designed to keep terms exactly the same across the market. The arogya sanjeevani policy coverage rules do not change whether you buy it from a private insurer or a government company.
Every claim has a mandatory 5 percent copay (Star Health). This means you pay 5 percent of the final approved hospital bill from your own pocket. The insurance company pays the remaining 95 percent directly to the hospital or reimburses you.
Room rent is capped at 2 percent of your sum insured, up to a maximum of ₹5,000 per day (sbigeneral.in). Intensive care unit charges are capped at 5 percent of your sum insured, up to ₹10,000 per day.
What the Arogya Sanjeevani policy is
IRDAI created this standard policy so buyers could get health insurance without hidden conditions. Every health and general insurance company in India must offer it. The arogya sanjeevani policy benefits are fixed by the regulator.
Initially, the policy was capped at a ₹5 lakh sum insured. IRDAI later removed this maximum limit under the updated IRDAI guidelines. This change allows you to buy much higher cover amounts, such as ₹10 lakh or ₹15 lakh, depending on what the insurance company offers.
The policy rewards you with a cumulative bonus of 5 percent for every claim-free year (Star Health). This bonus increases your cover amount without increasing your premium. The bonus grows up to a maximum of 50 percent of your original sum insured.
You can buy this policy for yourself or as a family floater plan. A family floater plan covers you, your spouse, your parents, and your dependent children under a single sum insured. The entry age for adults is between 18 and 65 years, and the policy can be renewed for life.
How the coverage and limits work
The policy defines strict limits for different types of hospital expenses. You must understand these limits before you file a claim.
Hospital room rent and ICU limits
The arogya sanjeevani room rent limit is strictly 2 percent of the sum insured, capped at ₹5,000 per day. Intensive Care Unit (ICU) charges are limited to 5 percent of the sum insured, capped at ₹10,000 per day.
If you choose a room that costs more than your limit, the insurer applies a proportionate deduction. The insurer will reduce the payout for your doctor fees, nursing charges, and diagnostic tests by the same percentage.
| Hospital bill component | Actual billed amount | Amount approved if room limit is breached |
|---|---|---|
| Room rent | ₹8,000 | ₹5,000 |
| Surgeon fee | ₹50,000 | ₹31,250 |
| Nursing charges | ₹10,000 | ₹6,250 |
The mandatory 5 percent copay
The arogya sanjeevani copay of 5 percent applies to all claims. This rule applies regardless of your age, the medical condition, or the hospital you choose. You cannot buy an add-on cover to remove this 5 percent copay from the Arogya Sanjeevani policy.
If your approved hospital bill is ₹1,00,000, you will pay ₹5,000. The insurance company will pay the remaining ₹95,000. You must pay this 5 percent share at the time of discharge.
Pre and post hospitalisation
The policy covers medical expenses for 30 days before you are admitted to the hospital (sbigeneral.in). It also covers recovery costs for 60 days after you are discharged. This pre and post hospitalization benefit includes doctor consultation fees, pharmacy bills, and diagnostic tests.
You must submit the original bills and prescriptions to claim these expenses. The tests and medicines must be directly related to the condition you were treated for in the hospital. If a test is not related to the primary illness, the insurer will reject that specific bill.
Cataract and modern treatments
The cataract surgery limit is clearly defined in the policy document. Cataract surgery is covered up to 25 percent of your sum insured or ₹40,000 per eye, whichever is lower (sbigeneral.in).
| Sum insured | 25 percent limit | Maximum allowed per eye | Final cataract cover |
|---|---|---|---|
| ₹1,00,000 | ₹25,000 | ₹40,000 | ₹25,000 |
| ₹3,00,000 | ₹75,000 | ₹40,000 | ₹40,000 |
Modern treatments are covered up to 50 percent of the sum insured. This includes procedures like robotic surgeries, stem cell therapy, and balloon sinuplasty.
What to check before you buy
Before you purchase this plan, you must check the waiting periods and the hospital network.
The 3-year waiting period for pre-existing diseases
The arogya sanjeevani waiting period for pre-existing diseases is 3 years. You cannot claim for medical conditions you already had before buying the policy until this period passes. This limit was recently reduced from 48 months to 36 months across all health policies.
Specific surgeries also have defined waiting periods before you can claim for them. Hernia repairs have a 24-month waiting period. Joint replacements have a 36-month waiting period.
What the policy does not cover
You must read the arogya sanjeevani exclusions before buying the policy. The policy does not pay for regular outpatient doctor visits or routine health checkups.
Major exclusions include cosmetic surgery, weight loss treatments, and injuries from adventure sports. Maternity and childbirth expenses are permanently excluded from this policy (sbigeneral.in). You cannot claim for pregnancy-related hospitalisation or newborn baby care.
Network hospitals for cashless treatment
The policy rules are standard across the market, but the hospital network depends entirely on the specific insurance company you buy it from. You must check if your preferred local hospitals are on the insurer's cashless network list.
A cashless claim means the hospital bills the insurance company directly. You only pay the 5 percent copay and any non-medical items like admission fees. If you go to a non-network hospital, you must clear the entire bill first and submit the original documents for reimbursement later.
Common mistakes when using this policy
Policyholders often face high out-of-pocket bills when they misunderstand the policy rules.
- Upgrading hospital rooms: Choosing a private hospital room that costs more than your 2 percent limit triggers a proportionate deduction. The insurer will reduce the payout for doctor fees and tests by the same percentage, leaving you with a massive bill.
- Forgetting the copay: Failing to budget for the mandatory 5 percent copay when planning a scheduled surgery causes unexpected expenses at discharge.
- Expecting maternity cover: Assuming a family floater plan automatically covers maternity is a common error. Arogya Sanjeevani strictly excludes maternity and newborn care.
- Ignoring the AYUSH limits: Assuming AYUSH treatment can be done anywhere is incorrect. You must take Ayurveda, Unani, Siddha, or Homeopathy treatments at a government hospital or a recognised institute to get the claim approved.
- Ignoring non-medical expenses: The policy does not cover non-medical items like gloves, registration charges, or admission kits. You must pay for these consumables out of your own pocket.
FAQs
Is maternity covered in Arogya Sanjeevani?
No, maternity and childbirth expenses are permanently excluded. You cannot claim for pregnancy hospitalisation or newborn care under this policy.
Can I buy Arogya Sanjeevani policy for senior citizens?
Yes, the entry age for the policy is up to 65 years. Once you buy the policy, it can be renewed for life.
Arogya Sanjeevani policy me kya kya cover hota hai?
It covers inpatient hospitalisation, day care procedures, AYUSH treatments, and pre and post-hospitalisation costs. It also covers modern treatments like robotic surgery up to 50 percent of the sum insured.
Does Arogya Sanjeevani have a 5 percent copay?
Yes, a 5 percent copay is mandatory on all claims under this policy. You must pay 5 percent of the approved hospital bill from your own pocket.
What is the room rent limit in Arogya Sanjeevani?
Room rent is capped at 2 percent of your sum insured, up to a maximum of ₹5,000 per day. ICU charges are capped at 5 percent of your sum insured, up to ₹10,000 per day.
The short version
- The Arogya Sanjeevani policy is a standard health insurance plan with identical coverage rules across all insurers.
- Every claim requires a mandatory 5 percent copay from the policyholder.
- Room rent is strictly capped at 2 percent of the sum insured, up to a maximum of ₹5,000 per day.
- The waiting period for pre-existing diseases is 3 years.
- Maternity, cosmetic surgery, and regular outpatient visits are permanently excluded from coverage.
You can check the latest premiums, claim settlement ratios, and complaint volumes across different insurers on the Qrates health insurance directory.
Sources
- The New India Assurance (India's Premier Multinational General Insurance Company)
- Buy Arogya Sanjeevani Health Insurance Policy Online - IndusInd General Insurance
- Arogya sanjeevani customer information sheet (PDF, nivabupa.com)
- Insurance Regulator Removes Rs. 5 lakh Capping from Arogya Sanjeevani Policies
- SBI General Insurance
- IRDAI Imposes Six-Month Ban on Niva Bupa Health Insurance for EoM Violations, ETBFSI
- Niva Bupa faces IRDAI action for ₹248 crore expense breach: What policyholders need to know
- IRDAI 2026 Health Insurance Rules: 5 Changes to Know | Finvastra
Disclaimer
Qrates is an information directory. It takes no commission from any company listed and does not recommend products. Figures are taken from the sources named and dated, and they change; check the company's own page before you decide. This is not investment, credit, insurance or tax advice for your situation. Read the policy wording and the prospectus for the exact cover, exclusions and waiting periods. Insurance is the subject matter of solicitation.