Health Insurance with Fewer Exclusions

One of the biggest problems with health insurance plans are the exclusions. So, what are the exclusions in a health insurance plan? An exclusion excludes health insurance coverage for certain type of risks. Insurers have exclusions for risks, they are unwilling to insure.

Always go through exclusions before availing a health insurance plan. If you don’t, there could be shocks in an emergency situation. Study exclusions in health insurance plans before availing them.

You can’t have disease, accidents and all risks covered in a single health insurance plan. Health insurance plans have limitations and getting health insurance which covers maximum requirement, is an art.

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Health Insurance With Fewer Exclusions

What are the Exclusions in Health Insurance?

Pre-existing Diseases:

If you are suffering from a disease at the time of availing the health insurance plan, it’s called a pre-existing disease. Pre-existing diseases have a waiting period of 2-4 years. Pre-existing disease like kidney stones, cataract, arthritis and joint treatment are excluded in the waiting period.

See Also: Health Insurance Benefits

Pregnancy:

Pregnancy costs like childbirth and vaccination are not covered in the health insurance plan. Pregnancy has a waiting period of 1-2 years.

Surgery:

You might urgently need a surgery, but sadly dental and cosmetic surgery and joint replacement are not covered in the health insurance plan.

Alternative Treatment:

Homeopathy, ayurveda and unani are popular alternative treatment. These are in the exclusion list of most health insurance plans.

Sub-limits:

A sub-limit is a monetary cap imposed by the insurer on the medical insurance claim. There are sub-limits on hospital room rent, doctor’s consultation fees, ambulance charges and even pre-planned medical procedures like cataract removal and knee ligament reconstruction.

There could also be permanent exclusions like war injuries, HIV, intentional injuries and congenital diseases.

See Also: Family Health Insurance Plan

What are Sub-Limits in Health Insurance?

The insurer imposes sub-limits on room rent. The insurer covers hospital room rent, but only up to a particular limit. The insurer may include the general room or the semi-private room rent in the health insurance plan. A private room may entail payments from your pocket. Let’s say the insurer offers a health insurance plan with room rent cap of Rs 3,000 a day. If you take a hospital room of Rs 5,000 a day, you would have to shell out Rs 2,000 from your own pocket.

Hospital charges depend on the room availed during treatment. A private room costs more than a general or twin-sharing room. However, discuss the sub-limits with the insurer to avoid any confusion.

You also have sub-limits on specific treatment. You must check the diseases which come under the sub-limit clause. Even though the sum assured is high, these diseases are not covered under the health insurance plan. Let’s say there’s a sub-limit of 60% of sum assured for cancer treatment. If the total sum assured is Rs 10 Lakhs, you cannot claim more than Rs 6 Lakh because of the sub-limit clause.

See Also: Things To Consider While Availing Health Insurance Plans

Changes in Exclusion:

• The IRDA has standardized exclusions across health insurance plans. Expenses related to treatment of any illness is excluded within the first 30 days of the health insurance plan, except accidents.
• The insurer has stated that you cannot be denied insurance cover for modern treatments methods and procedures like oral chemotherapy and robotic surgery.
• The waiting period for lifestyle diseases like diabetes, hypertension and cardiac conditions cannot be more than 30 days, except for pre-existing diseases which are disclosed at the time of underwriting.
• Hospital billing charges varies across hospitals. Some hospitals subsume certain charges into the hospital room rent charge. This leads to discrepancy of hospital bills. The IRDA has created 4 standardized list of items.

You would find baby food, sanitary pads, laundry charges, internet and email charges, diapers as optional items. These are left to the insurer’s discretion vis-à-vis coverage. Some items are subsumed into the room charges like toothpaste, tissue paper, toothbrush and hand wash. 

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