Every group health insurance plan may specify different illnesses for coverage and the kind of expenses covered for those illnesses. Accordingly, everything else not covered is also defined variably by different plans. But there are certain provisions which make medical procedures commonly excluded from the coverage.

Such exclusions can be classified into the following categories:

  1. Preexisting Illnesses
  2. War/radiation induced illnesses/injuries
  3. Voluntary medical procedures/Tests
  4. Expenses for External durable items
  5. Dental and Pregnancy Related treatments

Pre-existing Illnesses

Preexisting illnesses are usually not covered by the group insurer for a specific period. However, if policy continues for a certain period these illnesses may also be covered. This period may range from 12 months to 48 months.

Some insurers may allow the coverage on payment of additional premium.

War/Radiation Induced Illnesses/Injuries

As is clear, in the event of war any injuries and illnesses in the affected areas will not get health insurance cover. This also applies to radiation injuries, which may occur even without a war.

Voluntary Medical Processes

This refers to vaccinations, plastic surgery, experimental treatments, circumcision, etc. These procedures will not be covered if done without a medical condition which requires them for treatment.

External Durable Items

External durable items include crutches, spectacles, lenses, hearing aids, wheel chair, etc. which are needed for regular use by the patient but not for treatment. The insurer will not cover any expense on similar equipment for external use, which is not needed for a treatment of a disease.

Dental and Pregnancy Related Treatments

Dental treatments which do not require hospitalization are usually corrective surgeries. Group insurers do not cover such treatments costs unless it is necessary for curing an illness. Insurers also do not cover pregnancy treatments like IVF, GIFT, or treatments needed due to childbirth complications.

Read More: What is covered under Group Health Insurance?

Thus overall, group insurance plans avoid covering expenses which are not related to or arising out of the insured employees’ need for medical attention. They also avoid catastrophic loss coverage by excluding war as a peril causing illness or injuries.

Case: 1

It was the first job of Arti Sharma after completing her engineering from a leading education institute in Pune. She joined J.S Engineering as a trainee engineer. In addition to offering benefits like free cab and meal, the company was also offering her a group health insurance policy. On her first day at J.S Engineering, the HR Manager unveiled her benefits of a group health insurance and asked her to fill the insurance form with details of family members whom were dependent on her and thus, she wanted to cover them.

Arti got excited to know that her group health insurance policy will cover her medical expenses. Without reading the policy document, she decided to go for a minor plastic surgery operation of her nose to remove a scar which she got during childhood. She immediately contacted a plastic surgeon of one of the leading hospitals and went for the surgery.

Though the surgery removed her scar; she got a major blow when she approached her corporate health insurer to cover her medical bills. The insurer rejected her claim on the ground that the treatment was taken place for a ‘condition’ which was not medical and not suggested by the doctor. As the plastic surgery was happened for the beautification purpose and not for correction of a medical condition, the insurer refused the claim of Arti.

Case: 2

Jayant Gupta was working in L.K Construction as a senior technical analyst. The company was offering comprehensive group health insurance to all its 500 employees and their family members.

Last year, Jayant approached his group health insurer with the expenses he incurred on buying the wheel chair for his father who was recuperating after a heart attack and had a problem in walking. However, the insurer denied his wheel chair claim as it was considered as the expenses incurred for durable items which were not related to medical.

Read More: What are additional benefits available under Group Health Insurance?

Here it is interesting to note that when Jayant approached the insurer with medical expenses which he incurred on his father’s hospitalization after a heart attack, they were covered by the insurer.

However, in this case, the insurer refused to cover wheel chair expenses even when they were linked to his heart condition for which the claim was accepted by the insurance company. As wheel chair was considered as an external durable item, expenses incurred on it were not reimbursed by the group health insurance.

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