As healthcare costs continue to rise across India, many policyholders are questioning whether a coverage of Rs. 5 lakh is adequate to deal with the expenses of major medical procedures. With hospitals becoming more advanced and treatments more specialised, the cost of surgery, hospital stay, medications, and diagnostics can quickly add up. A 5 lakh health insurance plan has long been considered the baseline for individual coverage, but in 2025, its adequacy depends on various factors such as location, type of illness, hospital preferences, and the complexity of treatment.
This article examines whether Rs. 5 lakh is enough to cover major surgeries, compares it with the value offered by a 10 lakh health insurance plan, and outlines how to assess the right sum insured based on your personal and family needs.
Understanding what Rs. 5 lakh health insurance typically covers
A 5 lakh health insurance policy provides reimbursement or cashless treatment for hospitalisation up to Rs. 5 lakh per policy year. This includes:
- In-patient treatment (hospital room, doctor’s fees, ICU)
- Pre and post-hospitalisation expenses
- Daycare procedures (such as cataract or chemotherapy)
- Ambulance cover
- Certain add-ons like AYUSH treatments or domiciliary care
In many tier-2 and tier-3 cities, this amount may still be sufficient for moderate procedures like appendectomies, gallbladder removal, or minor orthopaedic surgeries. However, in metro cities or private super-speciality hospitals, the same Rs. 5 lakh could be exhausted quickly, especially when dealing with cardiac surgeries, cancer treatment, or organ transplants.
Common surgeries and their approximate costs in 2025
To better understand whether Rs. 5 lakh is enough, it helps to consider the current cost of some major surgeries in India:
- Heart bypass surgery (CABG): Rs. 3.5 lakh – Rs. 6 lakh
- Knee replacement (single): Rs. 2.5 lakh – Rs. 4 lakh
- Kidney transplant: Rs. 5 lakh – Rs. 8 lakh
- Cancer treatment (including chemo/radiation): Rs. 6 lakh – Rs. 15 lakh annually
- Liver transplant: Rs. 15 lakh – Rs. 25 lakh
In each of these cases, a 5 lakh health insurance plan may only partially cover the costs, leaving the rest to be paid out-of-pocket. Additionally, costs for post-operative care, complications, extended hospital stay, or follow-up diagnostics may not be fully covered within the limit.
Where a 10 lakh health insurance policy offers better protection
A 10 lakh health insurance policy offers broader financial security in times of serious health emergencies. It provides ample cushion for high-end surgeries, long-term treatments like cancer, and unpredictable complications. The key advantages include:
- Higher room rent limit: You are more likely to be eligible for private rooms in top-tier hospitals.
- Better hospital access: Premium hospitals in metros may only allow admission under higher sum insured plans.
- Coverage for recurring procedures: Some illnesses require multiple surgeries or sessions (e.g., dialysis, chemotherapy).
- No-claim bonus impact: With Rs. 10 lakh, even if your sum insured increases via no-claim bonus, the base itself remains strong.
If your 5 lakh health insurance plan has been in place for a while, and your premiums are affordable, upgrading to a 10 lakh health insurance policy could offer better peace of mind without a major cost increase—especially with the availability of super top-up plans.
When Rs. 5 lakh may still be sufficient
Despite the rising costs, there are scenarios where Rs. 5 lakh may still suffice:
- You live in a non-metro city with access to quality care at moderate prices.
- You have employer-provided group insurance that supplements your personal policy.
- You are under 30 years of age, with no family history of critical illness or lifestyle disease.
- You are combining your 5 lakh cover with a super top-up plan, increasing total cover affordably.
However, this adequacy is often short-lived. As you age or your family’s health needs evolve, Rs. 5 lakh may begin to feel inadequate—especially during sudden emergencies.
The importance of reassessing sum insured regularly
Your sum insured should reflect inflation, lifestyle, and changing medical risks. A cover that was suitable five years ago may not be enough today. In 2025, it is recommended that individuals review their health insurance annually and increase coverage if:
- Medical inflation in your area is consistently high
- You or your family have developed chronic illnesses (e.g., diabetes, hypertension)
- Your preferred hospitals fall in higher-cost categories
- You have dependents who may require maternity or paediatric care
For families, a 10 lakh health insurance plan under a family floater setup offers shared protection while keeping premiums reasonable.
Should you combine base cover with riders or top-ups
If affordability is a concern, it is possible to maintain a base 5 lakh health insurance policy and add a super top-up plan that activates once your base coverage is exhausted. This strategy is particularly useful when:
- You want higher cover without paying high premiums upfront
- You have existing coverage from your employer
- You are concerned about long-term illnesses or hospitalisation risks
Likewise, you can consider critical illness or personal accident insurance riders to cover specific risks beyond hospitalisation.
Conclusion
In 2025, a 5 lakh health insurance policy may still provide a safety net for moderate treatments, especially in smaller cities or under specific conditions. However, when it comes to major surgeries, advanced treatments, and long-term care, it may not always be sufficient. A 10 lakh health insurance plan offers stronger protection, wider hospital access, and a buffer against medical inflation.
Choosing the right sum insured requires evaluating your family’s health needs, financial situation, location, and future risks. Whether you choose to upgrade your coverage or combine policies with top-ups, ensure your health insurance aligns with the realities of modern healthcare costs—so that you are not caught unprepared during a medical crisis.
