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Exclusions of Health Insurance Policy Research Team | Posted On Wednesday, May 16,2018, 05:53 PM

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Exclusions of Health Insurance Policy



How would you feel if your Health Insurance Policy doesn’t cover a particular hospitalisation or an illness, despite being prompt on paying premiums and renewing your policy?  You would obviously feel like you paid the premiums for absolutely nothing. That is why you need to be aware of the exclusions of your Health Insurance Plan.

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Exclusions of Health Insurance Policy:

Exclusions are services that are not covered by a Health Insurance policy. You have to be very mindful while going through exclusions otherwise you may end up inviting trouble during claim settlement. Although Health Insurance exclusions are unique to every insurer, following are some of the common exclusions of a Health Insurance Policy:

1)  Permanent exclusions:

Intentional injuries, injuries in war, HIV, congenital diseases, and others are permanent exclusions.

Therefore, it is wise that you read the fine print carefully before signing up for a Health Insurance Plan. Ask your insurer about the exclusions. If you have any queries, ask him to clarify your doubts.

2) Pre-Existing Diseases:

You must disclose all your existing diseases to the insurer at the time of applying for a Health Insurance plan. Based on your account of your health, your insurer may suggest you to take a medical test. It is best to go for it because then the insurer cannot blame you for not disclosing your health condition. Also, he cannot refuse to cover your hospitalization expenses saying that a particular health condition was not disclosed.

Also, all pre-existing diseases have a waiting period ranging from 2-4 years before coverage begins.

3) Surgeries:

Usually, surgeries like joint replacement, cosmetic surgery, and dental surgery are not covered, except in case of accidents.

4) Waiting Period Clause:

You cannot avail a Health Insurance policy today and make a claim on the very next day. Every insurer will have a general waiting period of 1-3 months after which you can enjoy all the benefits of the policy. Suppose, you avail a Health Insurance plan today. Tomorrow if you fall sick, you cannot go to your insurer and make a claim on your policy. You will be sent right away! The only exception to this exclusion is accidents.

5) Pregnancy:

Pregnancy is generally excluded. All pregnancy related costs like childbirth, vaccination and others are not covered immediately. It is covered after a waiting period of 2-4 years.After serving the waiting period too, your policy may cover only up to a certain extent.

Say that you have a Health Plan of Rs 3-5 Lakhs. The maternity benefit will be limited. Say that they are capped at Rs 50,000 or so. Therefore, you can claim maternity expenses up to the limit only. Also, some policies do not cover the new born.

SEE ALSO: 5 Health Insurance Mistakes Which Can Cost You

6)  Alternative Treatment:

Many insurers do not cover alternative treatments like Ayurveda, Homeopathy and Unani. However, some insurers cover this, but cap the amount covered (usually 7.5% to 25% of sum insured). Only Allopathic treatment is fully covered.

7)  Hospital Costs:

Sub-limits are the maximum amount an insurer pays towards hospitalization costs like room rent, doctors fees, ambulance cost and so on.

For example, there’s a 1% per day cap in a Health Insurance policy on room rent. This means, there is a sub-limit on room rent and it is limited to Rs 5,000 a day if a health insurance plan has a sum insured of Rs 5 Lakhs. You can stay in a room with a tariff of up to Rs 5,000 per day.

8) Lifestyle-Induced Diseases:

Unless specified at the time of application, lifestyle-induced diseases which arise due to smoking, drinking, drugs and a stressful job are excluded. They might be included if you pay a higher premium on being asked by the insurer.  

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