Article

Exclusions in Health Insurance Policies- Know Them
July 08 , 2013

One of the things you can do to minimize chance of disappointment in health insurance claim is to be aware of what the policy will not cover. The last thing you want is to realize that your particular claim is under the policy's pre-defined exclusions list. Here we highlight some of the common exclusions in a health insurance policy.

General exclusions in health insurance policies

IRDA mentions a list of exclusions which are commonly applicable in any mediclaim hospitalization policy. They are mainly of 3 types:

a. Pre-existing diseases

b. Time-bound exclusions

c. Permanent exclusions

Pre-existing diseases exclusion in mediclaim policies

Pre-existing diseases are conditions- regardless of whether they were diagnosed or not-, illnesses, injury which were diagnosed, got medical treatment for or had symptoms  before buying the mediclaim policy. Any complications directly or indirectly related to the pre-existing diseases will be excluded.

Time-bound exclusions in health insurance plans

Certain conditions are covered after lapse of specified duration. They come under one of the following categories:

1) 30 days initial waiting period in mediclaim

Any claims within the first 30 days of policy start are not entertained. Accidental injuries are an exception to this. This exclusion applies only in case of first year of policy.

2) Specific waiting period in health insurance policy

Certain conditions are covered after a waiting period. Some insurers cover them in stages- certain conditions would be covered from the second policy year, some from the third and rest from the fourth.

  • Stones in biliary and urinary systems
  • Lumps/ cysts/ nodules/ polyps/ internal tumour
  • Gastric and Duodenal Ulcer
  • Surgery on tonsils/ adenoids
  • Osteoarthrosis/ Arthritis/ Gout/ Rheumatism/ Spondylosis/ Spondylitis/ Intervertebral/ Disc Prolapse
  • Cataract
  • Fissure/ Fistula/ Haemorrhoids
  • Hernia/ Hydrocele
  • Chronic Renal Failure or end stage Renal Failure
  • Sinusitis/ Deviated Nasal Septum/ Tympanoplasty/ Chronic Suppurative Otitis Media
  • Benign Prostatic Hypertrophy 
  • Knee/ Hip Joint replacement (unless needed because of accidental injury)
  • Dilatation and Curettage  
  • Varicose veins
  • Dysfunctional Uterine Bleeding/ Fibroids/ Prolapse Uterus/ Endometriosis   
  • Diabetes and related complications
  • Hysterectomy for any benign disorder

Note that none of these will be covered if you had trace of them before buying the policy.

Permanent exclusions in mediclaim

The ones in this list are not covered at any time unless specifically mentioned 

  • Addictive conditions and disorders due to substance abuse, alcohol etc
  • Ageing and puberty related (eg menopause)
  • Artificial life maintenance if it will not result in recovery or restoration of previous state of health
  • Circumcision (unless if needed for treatment of a disease or because of accidental injury)
  • Conflict and disaster
  • Congenital conditions
  • Cosmetic surgery
  • Dental/oral treatment
  • Drugs and dressings for Out-patient or take-home use
  • Eyesight (except if required because of an accident)
  • Experimental treatment
  • Health hydros, nature cure, wellness clinics etc
  • HIV and AIDS
  • Hereditary conditions

You can get cover for some health insurance exclusions

Many exclusions vary from insurer to insurer, especially in the permanent exclusions list. Carefully check the list of exclusions before buying any policy. It is possible to find policies that specifically cover some of the cases that are generally excluded or have lesser exclusion period. Of course, these would come at a higher cost.

For instance there are family floater policies that provide maternity and child care benefits. So you would have to shop for the right policy for you. Even companies that generally exclude a particular condition may agree to cover it for additional premium.

But remember that it should cost significantly lesser than the medical expense you might incur on it or the purpose of insurance is not served.

Conclusion

Sometimes it may be possible to override health insurance exclusion by paying extra premium. Before you choose a mediclaim policy, glance through the list of policy exclusions. If there is any specific condition in the list for which you require coverage discuss this with the company if it would provide cover on payment of higher premium or seek other policies that specifically cover it for lesser premium.

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