Health Insurance Exclusions
Health Insurance

Health Insurance Exclusions

A common misconception about health insurance policies is that they would pay for any kind of health care expenditure. Policyholders usually donot read the policy documents carefully and, as a result, are completely unaware of the common health insurance exclusions.

For starters, exclusions refer to the healthcare expenses that are not covered under your insurance policy and would have to be borne by you. Specific exclusions may vary from policy to policy, but there are some common exclusions from health coverage that you should know in order to avoid any confusion at the time of claim settlement.

Let’s take a look at some general medical insurance exclusions that find a mention in most health policies:

Pre-existing diseases: Generally, insurance policies do not provide coverage against pre-existing diseases, meaning diseases the policyholder was already suffering from at the time of buying the health plan. Even if some insurers provide coverage against pre-existing diseases, there might be a waiting period of 2-4 years before your policy starts paying for the expenses related to these ailments. Anything from arthritis to kidney stones or cataract can be classified as a pre-existing disease if it was diagnosed before the health policy was purchased.

30-day waiting period: No health insurance policy, irrespective of the insurance provider, would pay for any expense related to the treatment of any illness within the first 30 days of buying thepolicy. Only claims arising due to an accident would be considered if they are covered by the policy in general.

Investigation and evaluation: Expenses related to diagnostics or evaluation purposes are mostly excluded.Therefore, laboratory tests or imaging tests such as X-Ray, ultrasound etc. that are routinely conducted but are quite expensive would not be covered by your policy.

Rest, rehabilitation and respite care:Expenses related to enforced bed rest and not for receiving treatment during hospitalisation are generally excluded in your policy. Insurers may, however, develop add-on riders to offer respite care and home care, especially for people aged 65 and above.

Cosmetic or plastic surgery: One of the most unknown but common exclusions in health insurance policies is cosmetic or plastic surgery or any treatment done to change appearance. Such expenses are covered only if reconstruction of organs is required following an accident, burn or cancer or as part of medically necessary treatment to remove a direct and immediate health risk.

Maternity benefit: Most health policies do not cover expenses related to pregnancy, child birth or fertility treatments. The insurers offering these benefits would have a certain waiting period requirement for these expenses.

Self-harm: Expenses related to treatment of injuries caused due to a suicide attempt or any act of self-harm are excluded from policy coverage.

Alcoholism/substance abuse: Medical insurance exclusions include expenses related to treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof.

Change-of-gender treatment: Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex come under medical insurance exclusions.

Hazardous or adventure sports:Expenses related to any treatment necessitated due to participation in hazardous or adventure sports like para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing, scuba diving, skydiving, deep-sea diving, etc. won’t be covered under your health insurance policy.

Dental, vision and hearing:Expenses related to the correction of eye sight or hearing impairment dental treatment are usually not covered under medical insurance policies.

To conclude, it would be considered wise to understand the exact exclusions and waiting period requirements of your health insurance policy in order to avoid any unpleasant surprises at the most vulnerable times.

Disclaimer: The above information is indicative in nature. For more details on the risk factor, terms and conditions, please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale.

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