Group Health Insurance

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Typically, individual health insurance plans specify exclusions. These are conditions or ailments that insurers do not cover. A significant advantage of group health insurance plans is that insurers often waive off many of these exclusions. However, in order to lower premium costs, some groups might accede to such exclusions. This post looks at some common treatments which are not covered by group health insurance policies.

Types of exclusions in health insurance

Exclusions in health insurance can be classified as:

  1. Pre-existing illnesses
  2. War/radiation-induced illnesses/injuries
  3. Voluntary medical procedures/tests
  4. External durable items
  5. Dental and pregnancy-related treatments

Pre-existing illnesses

This is not an exclusion precisely, but insurers might not immediately cover pre-exiting illnesses. Individual health insurance policies usually have a considerable waiting period (of 24-48 months) for pre-existing illnesses. However, group health plans usually waive this waiting period. This means that the policy covers pre-existing illnesses from day one. In fact, this is a distinct advantage that group health plans have over individual ones.

Illnesses/injuries caused by war/radiation

Insurers typically do not cover injuries or illnesses that result from war. This also applies to radiation injuries, which may or may not be related to war. It is extremely difficult to waive off these exclusions.

Voluntary medical processes

This exclusion refers to vaccinations, plastic surgery, experimental treatments, bariatric surgery, circumcision, etc. Unless such procedures are part of the treatment for a medical condition, insurers usually do not cover them.

External durable items

A patient may need crutches, spectacles, lenses, hearing aids, wheelchairs, etc. for regular use. However, these may not be part of prescribed treatment. Insurers do not cover expenses incurred on such equipment for external use when it is not part of the treatment of a condition. In fact, in many cases, insurers do not cover these items, even if prescribed by a doctor. For example, insurers generally exclude sleep apnoea machines even if they are medically necessary.

Dental and pregnancy-related treatments

Dental treatments that do not require hospitalization are usually corrective surgeries. Group insurers do not cover such procedures unless necessary for the treatment of an illness. Insurers also do not cover fertility treatments like IVF, GIFT. Treatments necessitated by childbirth complications are also not covered under group health insurance policy.

Additional Read: What is covered under Group Health Insurance?

Case study: Plastic surgery as an exclusion

Arti Sharma completed her engineering from a leading educational institute in Pune and joined JST Engineering as a trainee. In addition to benefits like free transport to the workplace and free meals, the company offered a group health insurance policy.

Arti was excited to learn that her group health insurance policy would cover her medical expenses. Without reading the policy document, she decided to opt for a minor operation to remove a scar on her nose left behind by a childhood injury. She contacted a leading plastic surgeon to conduct the surgery that would help remove it.

The surgery removed her scar. However, she was shocked when she approached her corporate health insurer with her medical bills. The insurer rejected her claim on the grounds that her treatment was for a non-medical condition. Moreover, Arti had chosen to get the procedure; her doctor had not prescribed it.

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