This study explores the socio-demographic factors that affect health insurance uptake in urban India, utilizing data from the National Family Health Survey 2019–21 (NFHS-5). Although there has been a significant increase in health insurance coverage from 10.4% of households in 2005–06 to 38.1% in 2019–21, urban areas continue to face considerable challenges, with 62% of the population remaining uninsured. The findings indicate notable disparities driven by socioeconomic, demographic, and regional factors. Households with greater financial inclusion, such as those with bank accounts, show significantly higher odds of having health insurance than those without. Wealthier households and those possessing below poverty line (BPL) cards are more likely to be insured, highlighting the impact of health schemes targeting poverty. Additionally, gender dynamics play a role in coverage rates, with households owned by female members exhibiting a lower insurance uptake. Demographically, older individuals and smaller households are more likely to be insured. Caste and religion serve as significant determinants in access to insurance, with scheduled tribes and Christians having better access compared to scheduled castes and Muslims. Regional disparities are pronounced, with southern states achieving notably higher insurance penetration than their northern and eastern counterparts. The study emphasizes the necessity for tailored health insurance policies to address the unique challenges urban populations face, especially informal sector workers and economically vulnerable groups. The study offers evidence-based policy recommendations to enhance insurance uptake, including strategies to improve awareness, streamline enrollment, and address gender-specific and regional disparities in urban India. The findings underscore the need for differentiated policy approaches that account for socioeconomic heterogeneity within urban populations, particularly focusing on vulnerable subgroups such as female-headed households and the urban poor.