It is common knowledge that all health insurance plans come with a set of inclusions and exclusions. But often people overlook such exclusions and are interested only in the inclusions. Don’t make the mistake of focusing on what the policy offers while purchasing a health insurance plan.
Since exclusions in health insurance policies are not the best selling point, insurance providers tend to minimise any discussion about them. As an investor, it becomes the investor’s duty to understand every ‘what-if’ associated with buying a health insurance plan.
Knowledge of medical insurance exclusions can help someone avoid pitfalls in the form of permanent exclusions in health insurance.
- Reasons for claim rejection
Getting a claim rejected can be quite disappointing for anyone. Here’s a list of common mistakes a person may make that lead the insurance company to reject your claim request:
- Providing wrong or incomplete information
- Raising a claim after health insurance has expired
- Raising claims beyond the exhaustion of coverage limit
- Claiming for exclusions in health insurance policies
- Here’s a list of 13 exclusions in health insurance policies
Every medical insurance policy has different terms and conditions that determine the inclusions and exclusions of the plan. When investing in a health insurance policy, it is important to consider every aspect of the policy, especially the exclusions as they govern the approval status for all claims. Common exclusions from health coverage include the following:
1. Pre-existing diseases
The cost for the treatment of a pre-existing disease is a common exclusion in health insurance policies unless specified otherwise. For example, if a person has had a heart attack before purchasing health insurance, they will not be given coverage for another heart-related problem after purchasing the policy.
Some insurance providers who give coverage for pre-existing diseases have a waiting period after which the insured can raise a claim.
2. Maternity-related expenses
The expenses incurred for prenatal, postnatal, fertility, baby care, and birth control are common health insurance exclusions. However, few health insurance providers give coverage for these expenses after a certain wait period or after the addition of riders on top of the existing plan.
As per government guidelines, medical expenses for diseases such as HIV/AIDS can be permanently excluded from health insurance coverage. Hence, most insurers do not offer cover for these diseases.
4. Cosmetic treatments
Unless the treatment is considered necessary by the doctors (for example, in case of accidental injuries), expenses for cosmetic treatments (such as plastic surgery, body contouring, or body implants) are categorised as permanent exclusions in health insurance. If the treatment is a choice made by the insured to improve their appearance, they have to bear the expenses yourself.
5. Treatment for dental, vision, and hearing issues
Since most medical treatments of eyes, ears, and mouth do not require hospitalisation, medical expenses for these treatments are not commonly covered under a health insurance policy. However, if any one of these treatments is done while a person is hospitalised, they might get coverage.
6. Lifestyle diseases and deliberate injuries
Expenses for the treatment of lifestyle diseases (caused by poor health choices) or injuries that result from inflicting self-harm are grouped under permanent exclusions in health insurance policies.
7. New or alternative treatments
Treatments such as homeopathy, naturopathy, acupuncture, Ayurveda, magnetic therapy, and other alternative therapies are some common health insurance exclusions. A part of the reason for this exclusion is that determining exact coverage for these methods is quite difficult as many of these treatment options are unregulated.
8. Congenital diseases and extreme circumstances
Treatment for ailments that occur before a person’s birth (congenital diseases) is another common health insurance exclusion. In addition, medical expenses for injuries due to war, nuclear activity, and natural disasters are also not covered by insurance providers.
9. Diagnostic tests with negative results
A common health insurance exclusion is the medical expenses for diagnostic tests that turn out to be negative and do not require further medical intervention.
10. Obesity/weight control
Medical expenses for weight control and/or obesity are permanent exclusions in health insurance. The only exception here is when the doctor suggests treatment for weight loss due to life-threatening effects of a person’s current weight.
11. Gender transformation
Treatments for gender transformation are permanent exclusions in health insurance as they are performed by people’s choice and are not a medical requirement for maintaining good health.
12. Breach of law
Medical expenses for injuries incurred in an unlawful activity performed by the insured are not covered under health insurance.
13. Expense for rehabilitation, respite care, and rest cure
Expenses for substance abuse rehabilitation are common medical insurance exclusions. Apart from this, expenses for enforced bed rest are also not included.
- Waiting period clause
All health insurance policies come with a waiting clause—one cannot claim for any medical expense during this waiting period even if it is a medical emergency. This waiting period lasts anywhere from 30 to 90 days.
Here’s a list of some common medical insurance exclusions and waiting period associated with them:
- Pre-existing diseases: 2–4 years
- Conditions like hernia, osteoporosis, and ENT-related disorders: 1–2 years
- Ailments such as internal tumours, spinal disorder, cataract, and tonsils: about 2 years
- Medical care for infants: about 90 days
It is important to check the waiting clause before finalising a policy. Consider common exclusions in medical insurance during the waiting period to make an informed decision. Note that exclusions may differ from insurer to insurer.
To make the most out of a financial investment (such as health insurance plan), read all the policy-related documents carefully to identify all exclusions in the medical insurance policy. Comparing a policy premium against the inclusions and exclusions is a good idea as it helps in decision making.