Individual Insurance

What does a Health Insurance policy not cover?

You do not know what can happen tomorrow. Buying a health insurance policy without knowing the restrictions and exclusions is not a good move. Awareness of exclusions is equally important as of the scope of coverage. Health insurance manages your medical cost. But there are some treatments which health insurance does not cover. It is crucial to check for waiting periods, exclusions, sub-limits and co-payments.

Following are the standard exclusions prevalent under Health Insurance:

1) Pre-existing Diseases:

Any of the health insurance plans would not cover pre-existing diseases such as diabetes from day one. The generally waiting period is applicable to avail coverage of pre-existing diseases. Waiting period depends on the product. Normally it varies from 2 years to 4 years. The policy should be continued with the same insurer in order to avail coverage of pre-existing disease after waiting period.

2) Specific diseases:

There is a waiting period of 2 years for specified diseases. These include Cataract, Hernia, Joint replacements, Stones, any type of unwanted growing on or in the body etc.

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3) Cosmetic Surgery/ Treatment:

Any treatment or surgery for change of sex or any sort of complications or illness arising as a consequence thereof. Additionally, the policy will not cover personal comfort, cosmetics surgery, convenience and hygiene-related treatments and services.

4) Suicide Attempt:

Intentional self-injury, whether arising from an attempt to commit suicide or otherwise; and injury or illness due to use, misuse or abuse of intoxicating drugs or alcohol.

5) Maternity:

Health insurance plans usually do not cover medical expenses related to childbirth and newborn baby. Treatment relating to birth defects and external congenital illnesses or defects or anomalies are excluded from a basic health policy.

There are some insurers which provide maternity benefit cover as an add-on. One needs to check with the insurer whether it offers the same or not. Young couples should always buy a health plan with maternity benefits.

6) Treatment for AIDS:

All expenses arising out of any condition directly or indirectly caused to or associated with Acquired Immuno Deficiency Syndrome (AIDS) whether or not arising out of HIV, Human T-cell Lymphotropic Virus, Type III (HTLV-III or IITLB-III) or Lymphadenopathy Associated Virus (LAV), or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome or condition of a similar kind are not covered in health insurance policy.

7) Criminal Activities:

Health plans excluded claims directly or indirectly related to criminal acts. Moreover, the policy terms will not cover any medical emergency due to war or nuclear power damage.

8) Other Exclusions:

Health policy does not cover dental treatment, cost of contact lenses, and hearing aids. Naturopathy treatment is also an exclusion.

These are the standard exclusions which remain outside the purview of claims. These medical treatments are excluded during the lifetime of the policy.

The policy does not cover some diseases and treatment during the first few years. Hence, the insured should know the pre-specified waiting period applicable.

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Case Study:

Rohit, a 28-year-old marketing executive bought a family floater health insurance policy plan with a sum insured amount 5 lacs. Insurance policy also covered his parents. Later, in the year, his mother suffered from a medical emergency and doctor recommended knee replacement operation to her.

Rohit asked the insurer for cashless hospitalization approval a week before the operation date. Unfortunately, the insurer denied the claim settlement as his health insurance did not cover surgeries.

He does not even have enough savings to bear the cost of knee replacement treatment. His misconception about the scope of coverage leads to such disappointment. That is why it is always recommended to know the exclusions before buying the health insurance policy.

Hence, always read the list of exclusions carefully while buying health insurance plans in order to negate the denial of claims in the future.