Most families believe their health insurance is solid as long as the sum insured looks sufficient and the brochure lists familiar benefits. But real coverage strength depends on layers that aren’t always visible — and these gaps often reveal themselves only during hospitalization. Understanding them early can prevent unexpected out-of-pocket expenses and emotional stress during already difficult moments. 1. Room Rent Limits Many plans still include room rent caps, which quietly restrict the category of rooms you can choose. If you’re admitted to a room above the limit, proportionate deductions apply across the entire bill — a detail most families discover only after the claim is processed. 2. Sub-Limits on Common Treatments Procedures like cataract, hernia, or joint replacements often carry sub-limits. Even with a ₹10 lakh policy, these caps can significantly reduce what the insurer pays. Brochures mention these in fine print, making them easy to overlook until the need arises. 3. Long Waiting Periods Waiting periods for pre-existing diseases, maternity, or specific illnesses can quietly delay access to coverage. Families assume they’re protected from day one, only to learn later that certain treatments aren’t eligible for reimbursement for months or years. 4. City-Based Cost Mismatch A sum insured that works in a Tier-2 city may not be adequate in metros like Mumbai or Delhi, where hospitalization costs are significantly higher. Traditional comparisons rarely account for this geographic mismatch, leading to underestimating the real cost of care. 5. Network Hospital Availability Having a cashless network hospital nearby is crucial, yet many policyholders check networks only during emergencies. If the nearest quality hospital isn’t on the list, families end up paying upfront and navigating reimbursement complexities. 6. Insurer Claim Behaviour Variations Two people with the same policy may still have different claim experiences due to regional service patterns, claim load, or variability in assessment. This inconsistency often comes as a surprise because brochures don’t show how an insurer performs in real-world claim situations. 7. Hidden Deductibles and Co-Pays Some plans include co-pays based on age, city, or treatment type. Others have deductibles that activate only under certain conditions. These hidden cost-sharing rules can reduce the final claim amount significantly. Traditional comparisons rarely highlight these real-world gaps because they focus on features, not context. This is where BimaAnalyze, developed by Alps Insurance Brokers Pvt. Ltd., brings deeper clarity. It starts with simple inputs — Pin Code, insurer name, age group, and sum insured — and maps them to over 100 analytical factors, including geographic medical costs, insurer claim efficiency, and policy structure patterns. The output is a BimaScore, a 400–1000 rating that reveals your true coverage strength and identifies hidden vulnerabilities specific to your profile and location. Looking ahead, BimaSolution, launching on March 31, 2026, will build on these insights to provide personalized health insurance recommendations tailored to each family’s unique needs. https://www.bimascore.com/