- Date : 04/08/2022
- Read: 4 mins
There are numerous Health Insurance Policy policies in the market that offer a different range of medical needs. While all standard covers have the same exclusions, one can always buy a more comprehensive cover or go for specific riders to be included in the cover. Let us understand Health Insurance covers better.
Deciding on a suitable health insurance plan for yourself and your family is an important job that needs to be done with a broad awareness of the inclusions and the exclusions of medical services in the medical policies. Thorough research and planning will help you choose a plan with maximum insurance coverage and fewer exclusions.
The insurance companies have a list of exclusions under each of their health insurance plans that are compliant with the Insurance Regulatory and Development Authority of India (IRDAI). Based on this, your insurer would approve or reject your claims for hospitalization.
Some of the common exclusions in health insurance covers are:
- Pre-existing diseases and chronic medical illnesses
In pre-existing diseases like diabetes, blood pressure, heart problems, etc., depending on your Health Insurance policy’s guidelines, the health plans may include these expenses only after the waiting period is completed, which can range from 12 months to 48 months. That said, newer health plans are being launched to provide the cover from Day. Furthermore, in some cases, the insurer may cover pre-existing diseases by paying an additional premium.
- Cosmetic Surgeries
Unless a cosmetic surgery is a part of the existing health treatment, insurance companies will not compensate for Cosmetic surgeries. As procedures like Liposuction, Botox, Body Implants, etc., are not performed to counter life-threatening or dangerous health conditions, they will not be claimable.
- Dental, vision, and hearing
Most medical insurance policies do not cover dental and vision procedures as they do not require hospitalization. However, if there is a need for hospitalization, it could be covered.
- Infertility treatments and Pregnancy-related complications
Basic health insurance does not cover hospitalization costs connected to infertility treatment and abortions. However, some women-specific health plans or maternity health plans may cover these.
- Alternative Therapies and Health Supplements
Alternative therapies like acupressure, naturopathy, acupuncture, reflexology, etc., are excluded from health insurance coverage.
Health supplements and wellness boosters like health tonics and protein shakes, which are not consumed to treat diseases, are not covered in insurance policies. Only certain doctor-prescribed medicines are covered.
- Alcohol consumption related diseases and illnesses due to substance abuse
In case of illnesses like liver damage resulting from overconsumption of alcohol, the insurance company has the authority to reject your claim for treatment costs entirely.
In cases of evident illnesses caused due to excessive smoking or other recreational drug consumption, claims can be repudiated on the grounds that the ailment was caused by alcohol abuse or smoking, etc. However, the patient can raise a dispute if not in agreement and show causation has to be established accordingly. This article from Tomorrow Makers gives an in-depth understanding of your rights if your insurance claim has been rejected.
- Diagnostics or Pathology Charges
Diagnostic or pathological services like blood tests, urine tests, scans, and other bodily tests that are required by hospitals to diagnose the problem/ disease are excluded unless it is specifically covered in certain policies or is a mandatory part of the treatment.
- Stem Cell therapy, robotic surgery, or cyberknife
Though some hospitals may recommend robotic surgery or stem cell therapy, these methods are still considered experimental in nature. As per insurance companies, any unproven or experimental treatment, which is not based on established medical practice, is common, but lesser-known would come under the exclusion list and are not considered claimable medical services.
- Injuries dues to self-harm or suicide attempts
Insurance plans will not cover any injuries resulting from intentional self-harm or suicide attempts.
- Certain drugs used during hospitalisation
Though Cancer is a critical illness, it does not have a blanket approval for all the treatment procedures involved in fighting Cancer. Some insurers exclude some cancer drugs, and most drugs under immunotherapy are not covered.
- Miscellaneous Charges
Charges incurred at any medical facility, such as registration fees, admission fees, service charges, and non-medical expenses, cannot be claimed in a health insurance plan.
While it is common knowledge that every health insurance policy is different, to avoid rude shocks of discovering exclusions later and managing your finances better, you should diligently read through policy wordings till the end. Know if your insurer covers the prescribed treatment or procedure recommended by your doctor or not. It is advisable to enquire with your health insurance provider if unsure, and also remember, many benefits can be added to an existing health plan, such as maternity cover, dental cover, etc., as additional riders with extra charges.
Deciding on a suitable health insurance plan for yourself and your family is an important job that needs to be done with a broad awareness of the inclusions and the exclusions of medical services in the medical policies. Thorough research and planning will help you choose a plan with maximum insurance coverage and fewer exclusions.
The insurance companies have a list of exclusions under each of their health insurance plans that are compliant with the Insurance Regulatory and Development Authority of India (IRDAI). Based on this, your insurer would approve or reject your claims for hospitalization.
Some of the common exclusions in health insurance covers are:
- Pre-existing diseases and chronic medical illnesses
In pre-existing diseases like diabetes, blood pressure, heart problems, etc., depending on your Health Insurance policy’s guidelines, the health plans may include these expenses only after the waiting period is completed, which can range from 12 months to 48 months. That said, newer health plans are being launched to provide the cover from Day. Furthermore, in some cases, the insurer may cover pre-existing diseases by paying an additional premium.
- Cosmetic Surgeries
Unless a cosmetic surgery is a part of the existing health treatment, insurance companies will not compensate for Cosmetic surgeries. As procedures like Liposuction, Botox, Body Implants, etc., are not performed to counter life-threatening or dangerous health conditions, they will not be claimable.
- Dental, vision, and hearing
Most medical insurance policies do not cover dental and vision procedures as they do not require hospitalization. However, if there is a need for hospitalization, it could be covered.
- Infertility treatments and Pregnancy-related complications
Basic health insurance does not cover hospitalization costs connected to infertility treatment and abortions. However, some women-specific health plans or maternity health plans may cover these.
- Alternative Therapies and Health Supplements
Alternative therapies like acupressure, naturopathy, acupuncture, reflexology, etc., are excluded from health insurance coverage.
Health supplements and wellness boosters like health tonics and protein shakes, which are not consumed to treat diseases, are not covered in insurance policies. Only certain doctor-prescribed medicines are covered.
- Alcohol consumption related diseases and illnesses due to substance abuse
In case of illnesses like liver damage resulting from overconsumption of alcohol, the insurance company has the authority to reject your claim for treatment costs entirely.
In cases of evident illnesses caused due to excessive smoking or other recreational drug consumption, claims can be repudiated on the grounds that the ailment was caused by alcohol abuse or smoking, etc. However, the patient can raise a dispute if not in agreement and show causation has to be established accordingly. This article from Tomorrow Makers gives an in-depth understanding of your rights if your insurance claim has been rejected.
- Diagnostics or Pathology Charges
Diagnostic or pathological services like blood tests, urine tests, scans, and other bodily tests that are required by hospitals to diagnose the problem/ disease are excluded unless it is specifically covered in certain policies or is a mandatory part of the treatment.
- Stem Cell therapy, robotic surgery, or cyberknife
Though some hospitals may recommend robotic surgery or stem cell therapy, these methods are still considered experimental in nature. As per insurance companies, any unproven or experimental treatment, which is not based on established medical practice, is common, but lesser-known would come under the exclusion list and are not considered claimable medical services.
- Injuries dues to self-harm or suicide attempts
Insurance plans will not cover any injuries resulting from intentional self-harm or suicide attempts.
- Certain drugs used during hospitalisation
Though Cancer is a critical illness, it does not have a blanket approval for all the treatment procedures involved in fighting Cancer. Some insurers exclude some cancer drugs, and most drugs under immunotherapy are not covered.
- Miscellaneous Charges
Charges incurred at any medical facility, such as registration fees, admission fees, service charges, and non-medical expenses, cannot be claimed in a health insurance plan.
While it is common knowledge that every health insurance policy is different, to avoid rude shocks of discovering exclusions later and managing your finances better, you should diligently read through policy wordings till the end. Know if your insurer covers the prescribed treatment or procedure recommended by your doctor or not. It is advisable to enquire with your health insurance provider if unsure, and also remember, many benefits can be added to an existing health plan, such as maternity cover, dental cover, etc., as additional riders with extra charges.
