Most Common Health Insurance Exclusions You Should Know Before Buying a Policy


Health insurance policies have always come to the rescue of people, and they are a convenient financial tool that lets you breathe a sigh of relief in times of dire need.

A large number of covid-related claims have been made following the increase in Covid cases during the second wave. As of May 5, 2021, approximately 47.8K covid claims have been repudiated while approximately 187.8K claims are still under review, according to data released by the General Insurance Council. These health insurance claims were mostly rejected for lack of proper documentation, waiting times and exclusions.

Dhirendra Mahyavanshi, co-founder of Turtlemint (An InsurTech Company) said that following IRDAI guidelines for proper consideration of covid claims before rejection, insurers have become much more inclusive in recent times.

“New and improved features such as coverage of mental disorders, robotic and advanced surgeries, inclusion of telemedicine, etc. broadened the reach of health insurance plans and made them popular. However, wait times and exclusions are still an important part of any health plan. Even with standardized exclusion standards, there are many things a policyholder should be aware of before purchasing the plan, ”Mahyavanshi told FE Online while explaining the most common health insurance exclusions that every policyholder should be aware of. Looked:

Exclusion for pre-existing illness during the waiting period

The co-founder of Turtlemint said that if you are suffering from a medical problem, like diabetes, hypertension, etc., such problem would be called a pre-existing problem. “Complications arising from such pre-existing conditions would not be covered for a waiting period specified in the policy. The period ranges from 12 months to 48 months. Once the period is over, you can get coverage for your pre-existing conditions.

Normal wait time

In addition to the waiting period for pre-existing conditions, there are also other waiting periods during which specified coverage is not available. These periods include the following:

Initial waiting period: Mahyavanshi said this is also called a cooling off period from the date the policy is purchased. Illnesses occurring during this period are not covered. However, accidental injuries would be covered during this period which generally lasts 30 days.

Specific waiting period: Diseases and treatments like hernia, fistula, tonsillectomy, cataracts, joint replacement surgeries, etc. are not covered for the first or two years of the policy.

Maternity waiting period: If the plan allows maternity coverage, there would be a waiting period during which coverage would not be available. The period ranges from 9 months to 48 months.

Cosmetic treatments: Cosmetic surgeries are not medically necessary except when they become important in treating an accidental injury. Such unnecessary cosmetic treatments are therefore excluded from the scope of the guarantee. In addition, even circumcision and sex reassignment treatments are excluded from coverage.

Non-scientific treatments: If you have unproven, experimental or unscientific treatments, the cost of those treatments would not be covered by your health insurance plan. Clinical trials are the most common examples of this and if you are receiving treatment in such trials, where the line of treatment is not generally accepted by healthcare professionals, you will have to bear the medical costs.

Self-harm: Injuries or illnesses sustained as a result of attempted suicide, deliberate acts by the insured or self-inflicted injuries are not covered by the policy. This is because health plans are meant to cover uncertain medical emergencies over which you have no control. If you control the occurrence of medical contingencies, those contingencies would be excluded from coverage.

Participation in dangerous activities, criminal acts and injuries sustained as a result of alcohol or drug abuse are also excluded from coverage.

Allied war and perils: Medical injuries sustained when the country is at war, or if there is a mutiny, rebellion or civil unrest, would not be covered. Illnesses and injuries due to radiation or chemical ionization are also not covered.

Investigation and evaluation costs: The medical costs caused by the investigative tests are covered on the condition that they are related to the treatment for which you were hospitalized. However, if the tests are unrelated to the treatment you are requesting, their costs would not be covered. In addition, if you are hospitalized solely for the purpose of undergoing investigative or evaluation tests, the costs of this hospitalization and these tests would not be covered.

Food supplements: Costs incurred for the purchase of vitamins, minerals and other food supplements are not covered by the policy.

Cost of consumables and non-payable items: Consumables are single-use items that are used during treatments. For example, cotton, bandages, syringes, face masks, disinfectants, etc. constitute consumables.

These consumables are not covered by health insurance plans and their costs would be your personal expenses. Similarly, the regulator has specified a list of items not payable under health insurance. The cost of the items contained in such a list is also not covered.

“However, modern health plans allow add-ons that allow you to claim coverage for these non-chargeable items and consumables.

3 conditions for obtaining a health insurance claim

According to Mahyavanshi, a health insurance claim would only be admitted if the 3 conditions are met, such as a doctor’s notice of hospitalization, a standard treatment protocol and an active treatment line have been administered.

“If all these 3 clauses are met and there is no exclusion or documentation problem, there is no reason to reject the claim. However, when buying a health insurance plan, read the fine print. Go through the list of coverage exclusions to find out exactly what is covered by the plan and what is not, ”he suggested.

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