⁠Hidden Clauses in Your Health Insurance that You Need to Know

Least Known Hidden Clauses in Health Insurance Policies

At first glance, a health insurance policy appears to focus on sum insured, coverages, ease of claim processes, and affordable premiums. However, there's much more to discover before you sign the papers.

Some of the hidden clauses that you may be least aware of are:

1.Sub-limit on Specific Diseases

Health insurance providers may have a list of specific diseases. These diseases may have sub-limits. This means you can up to a specific sum insured amount for the treatment of these listed diseases. 

For instance, suppose the sub-limit in a ₹10 lakh health insurance policy is ₹1 lakh or 20% of the claim amount for listed diseases. Now, if the insured individual requires treatment for any of the listed diseases, the maximum amount they can claim is ₹1 lakh or 20% of the sum insured. 

2.Room Rent Limit

Similar to listed diseases, hospital rooms may also have sub-limits. In such a situation, you can claim only a certain amount for the room rent. For instance, if the room rent sub-limit is ₹ 2,000 per day, any charges exceeding ₹ 2,000 will be payable by the policyholder. 

3.Co-Pay & Deductibles

Copayments and deductibles are two clauses that require the policyholder to pay. The copay is the portion of the claim amount that the policyholder is responsible for. Deductibles, on the other hand, is the amount that the policyholder has to pay before the insurance company starts paying. 

For instance, if the deductible is ₹5,000, the insurer will cover medical treatments exceeding ₹5,000. On the other hand, if the co-pay is 20%, you, the policyholder, will be responsible for bearing 20% of the total claim amount. 

4.Cashless Treatment Limitations

Cashless treatment is a preference of most people. With cashless treatments, you no longer have to bear the expenses and later raise reimbursement claims. Rather, the insurance company directly settles bills with the hospital. 

However, cashless treatments are usually available at select hospitals. If you seek treatment at a non-network hospital, you can only raise reimbursement claims. 

5.Waiting Period

The health insurance coverage do not start providing coverage from day 1 of the policy. That's only applicable for accidental injuries. Other than this, you need to wait for a specific tenure before you can raise claims. 

For instance, a policy may have an initial waiting period of around 30 days, a pre-existing disease waiting period that ranges between 12 and 48 months, a maternity waiting period that ranges between 9 and 36 months, and a specific illness waiting period of 12 to 48 months. 

You can only raise claims after the waiting period is over, or else the claims are rejected. 

6.Excluded Treatments

A health insurance plan does not cover all types of treatments. Apart from common exclusions like self-inflicted harm, war injuries, intoxications, etc., some other treatments may also be excluded. 

Depending on the type of health insurance policy you have, cosmetic treatments, infertility treatments, gender alteration treatment, etc., may not be covered. Some non-maternity health insurance policies also exclude maternity and childbirth expenses. 

How to Know About Hidden Clauses?

Since health insurance policies may have various hidden clauses, how can you debunk them? Following basic hygiene and tips can be enough. These are:

1.Read the Policy Documents

Before signing the documents, ensure you read them carefully. You must do it even if it seems boring, lengthy, and time-consuming. Health insurance is like an investment. So, do it wisely. 

2.Ask Questions

Do not hesitate to ask as many questions as you have to your insurer. If you do not understand a clause or term, remember that your insurer is there to help you. 

3.Understand Exclusions & Copays

Be very clear about the policy's exclusions, copayment, and deductible clauses. These can make a huge difference in the overall premium. 

A higher copay and deductibles mean lower premiums and vice versa. However, higher copay and deductibles also means higher claim burdens during times of need.