Medical expenses and conditions that your health insurance may not coverx

Date : 08/06/2021
Read: 5 mins

Before getting admitted to a hospital, a policyholder should know what is excluded from their health insurance plan. Here’s how to be forewarned.

Medical expenses and conditions that your health insurance may not coverx

A typical health insurance policy document is peppered with terms like deductibles, exclusions, co-pay, non-payables etc. Anyone buying a mediclaim insurance policy should look beyond the premium amount and the sum assured to get an idea of how much they will have to pay out-of-pocket in case of hospitalisation.

A hospital bill may have various cost components that fall outside the scope of coverage of your health insurance. Only a proper reading of the policy document can tell you which type of expenses or medical conditions are outside the scope of your hospital insurance.

Even cashless hospitalisation may involve some cash payment if any of the following items appear in your hospital bill. In view of the current pandemic situation, we have considered both COVID-19 insurance as well as regular insurance. Things to note when purchasing health insurance during COVID-19 pandemic

Making sense of the exclusions

Over and above sum assured: The portion of the hospital bill which is over and above the sum assured amount will be borne by the insured person.
Co-pay clause amount: If your health insurance has a co-pay clause, a portion of the medical treatment cost will have to be borne by you. For instance, if your health insurance has a 10% co-pay clause and your hospital bill is Rs 1 lakh, you will have to pay Rs 10,000, while the insurer will cover the remaining Rs 90,000.
Deductibles: This is a fixed amount that the insured person needs to pay towards hospital bill/treatment before the start of coverage of the health insurance. It is similar to co-pay but is a fixed amount instead of a percentage.
Pre-existing conditions: These refer to illnesses that have been diagnosed before the purchase of the health cover. The insurer will define a waiting period for such conditions and coverage will be available only after the expiry of the waiting period.
Permanent exclusions: These are illnesses that are permanently outside the scope of coverage. Examples include intentional injury, HIV/AIDS, war wounds, etc.
Non-payable items: Certain articles are considered ‘non-medical’ for health coverage calculations. There are around 200 such items that IRDA recognises as non-medical expenses. It includes hair removal cream, various baby-related expenses, sanitary pad, tissue paper, toothbrush and paste, gauze, face mask, etc. Items specifically excluded include expenses related to weight control, infertility, hormone replacement, psychiatric, STD, AIDS etc. Besides, administrative expenses like admission kit, birth certificate, courier, conveyance, diabetic and daily chart charges, and durable devices like walking aid, commode, arm sling, thermometer etc. are also among non-payable items. Among items relevant to COVID-19 treatment, PPE kits are allowed up to a limit, while nebulisers, steam inhalers, thermometers etc. are completely excluded.

In the case of COVID-19, exclusions may include medical expenses incurred during home quarantine or for a stay at a non-recognised quarantine centre. If you are hospitalised without the recommendation of a doctor, expenses arising out of such hospitalisation may not be covered.

While there is a 30-day waiting period in the case of most health insurance policies, in light of the medical emergency, some COVID-specific policies have a reduced initial waiting period of 15 days only.

How COVID claims are settled

In case of COVID treatment, a patient covered under the Corona Rakshak policy will get a benefit-based coverage of the entire sum assured, subject to the fulfilment of policy terms and conditions. Corona Kavach is like regular indemnity plans, where the insured person receives reimbursement against the hospital bill. Since all normal health insurance policies must mandatorily cover COVID treatment, it would be useful to review the two popularly followed claim processes.

Cashless claim settlement is provided by most leading insurance companies. However, such a facility is available only in a network hospital. It is convenient for the policyholder as the bill is directly settled with the hospital by your insurance company. If you need to get yourself or your family treated for COVID-19, getting admitted to a network hospital will relieve you from payment-related concerns. The list of network hospitals can be easily viewed online or on paper by requesting the insurance company.

Reimbursement claim settlement is necessary if you decide to get treatment in a non-network hospital, but not in a blacklisted hospital. Here, you have to pay the entire hospital bill at the time of discharge. Within a stipulated number of days after your discharge, you need to claim reimbursement with the insurer and provide documents such as hospital bill, reports, prescriptions, discharge summary etc. The insurer reviews the bill and processes the payment in your favour. If you have a Corona Kavach policy, your claim for treatment of COVID-19 will be settled in this manner.

Last words

The list of excluded items and conditions may amount to a higher sum in the case of COVID-19 because of the high expenses of consumables and non-medical items. But despite the exhaustive list of items that may not be covered by health insurance policies, a major portion of medical expenses incurred do get covered in case of most illnesses or medical procedures. In any case, knowing what these uncovered items are will prepare you financially in case of a medical emergency. 5 Reasons why your health insurance premium increase on renewal

Making sense of the exclusions

Over and above sum assured: The portion of the hospital bill which is over and above the sum assured amount will be borne by the insured person.
Co-pay clause amount: If your health insurance has a co-pay clause, a portion of the medical treatment cost will have to be borne by you. For instance, if your health insurance has a 10% co-pay clause and your hospital bill is Rs 1 lakh, you will have to pay Rs 10,000, while the insurer will cover the remaining Rs 90,000.
Deductibles: This is a fixed amount that the insured person needs to pay towards hospital bill/treatment before the start of coverage of the health insurance. It is similar to co-pay but is a fixed amount instead of a percentage.
Pre-existing conditions: These refer to illnesses that have been diagnosed before the purchase of the health cover. The insurer will define a waiting period for such conditions and coverage will be available only after the expiry of the waiting period.
Permanent exclusions: These are illnesses that are permanently outside the scope of coverage. Examples include intentional injury, HIV/AIDS, war wounds, etc.
Non-payable items: Certain articles are considered ‘non-medical’ for health coverage calculations. There are around 200 such items that IRDA recognises as non-medical expenses. It includes hair removal cream, various baby-related expenses, sanitary pad, tissue paper, toothbrush and paste, gauze, face mask, etc. Items specifically excluded include expenses related to weight control, infertility, hormone replacement, psychiatric, STD, AIDS etc. Besides, administrative expenses like admission kit, birth certificate, courier, conveyance, diabetic and daily chart charges, and durable devices like walking aid, commode, arm sling, thermometer etc. are also among non-payable items. Among items relevant to COVID-19 treatment, PPE kits are allowed up to a limit, while nebulisers, steam inhalers, thermometers etc. are completely excluded.