Common Exclusions in Health Insurance Policy


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Health Insurance policies provide coverage for numerous medical expenditures; however, one should be aware of the exclusions while purchasing the policy. Let’s understand insurance exclusions in this post.  

The key role of health insurance policies is to offer monetary assistance to individuals and families during the time of medical emergencies. A comprehensive health plan safeguards individuals from different expenses related to hospitalization and treatment. This allows the insured to concentrate on recovering and getting healthy rather than worrying about medical bills.

In general, health insurance companies provide coverage for most health conditions. But depending on the company policy, every insurer prepares a set of exclusions with their specific health plans. The exclusions include medical conditions for which the insurer either doesn’t offer coverage or allows coverage after a particular waiting period. Every policyholder needs to know about these exclusions. Being ignorant about them might cause distress at the time of raising health claims. To know these exclusions, one must read the policy document thoroughly.

Health insurance policy exclusions vary depending on insurance companies and particular insurance plans.

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Common Health Insurance Exclusions  

1. Waiting Period:

Every health insurance company has a set of waiting periods applied for different purposes under the plan. A policyholder has to go through the waiting period before enjoying the benefits of their health plan. You can’t raise a claim under your health insurance until you complete the waiting period as per the policy document. Some of the various waiting periods include:

  • Initial waiting period
  • Disease-specific waiting period
  • Maternity waiting period
  • PED or pre-existing diseases waiting period
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2. PED or Pre-Existing Diseases:

PEDs are the conditions that the insured already suffers from when purchasing the health policy. Almost all health insurance companies apply a PED waiting period for certain diseases. The duration of such a waiting period might range from 2-4 years.

3. Maternity Expenses:

In most cases, regular health insurance plans do not cover maternity expenses. If you are recently married and wish to start a family soon, you should confirm with your insurer if the plan chosen by you covers maternity costs like pre-and post-natal care, childbirth, newborn baby care, etc. Moreover, even if your policy covers maternity expenses, they might apply a waiting period of 2 or more years before you can avail the benefits. So, it is important to check it before buying the plan.

4. Mental Illness:

Until recently, most health insurance policies in India did not cover mental illness. However, the recent guideline of the Insurance Regulatory and Development Authority of India (IRDAI) has made it compulsory for all insurers in India to cover the treatment costs associated with mental health conditions.

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STDs or sexually transmitted diseases such as HIV/AIDS are also not covered under most of the health insurance policies.

6. Cosmetic Procedures:

Plastic surgery, body contouring or sculpting, or even breast enhancement are some cosmetic treatments that are generally not covered under most regular health insurance policies.

7. Dental Treatment:

Most health policies do not cover dental procedures unless the requirement of dental treatment comes from any accidental injury.

8. Self-Inflicted Injuries:

Injuries that are deliberately inflicted by the insured or any condition caused due to a case of attempted suicide are conditions in the self-inflicted injuries category that are not covered under your health insurance policy.

9. Permanent Exclusions:

Among the several permanent exclusions, congenital diseases or certain bodily conditions caused to the insured due to war or nuclear weapons are exclusions that are not covered under a health insurance policy.

Permanent Exclusions in Health Insurance 

As already discussed, almost all health insurance policies are available with certain exclusions known as common exclusions, which we read about in the section above. Apart from the common exclusions, every policy also has some permanent exclusions, typically bound by time and conditions. Hence, they can be termed conditional exclusions. It is equally essential for the policyholder to know about such permanent conditions. And to know and understand these permanent exclusions, you must read the policy document thoroughly.

For example, genetic blood disorders or certain chronic illnesses may never be covered under your health insurance policy for your entire life.

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To Sum Up

When it comes to insurance, quick decisions are not justifiable. Various things need consideration, and health exclusions under insurance policies are among them. Every insurer mentions the exclusions of the plan in the policy document, and you are advised to read the document carefully and understand them well before buying the plan. In case of insurance jargon you cannot comprehend, it is suggested to seek guidance from the insurance company by contacting their representatives. After ensuring the necessary measures, pick the best policy for yourself and your family.

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FAQs: Common Exclusions in Health Insurance Policy

What do you understand about health insurance exclusions?

Exclusion in health insurance means some medical conditions which are not covered under your health plan. Policies generally have common and permanent exclusions.

Which exclusions are regarded as the common exclusions under Health Insurance?

Some of the general exclusions under health insurance policies are:
~ PED or Pre-Existing Diseases
~ Cosmetic Procedures
~ Treatment for Obesity
~ Treatment for Substance Abuse
~ Treatment against hazardous sports injury
~ Mental conditions
~ Maternity expenses etc.

Are sub-limits different from exclusions in health insurance policies?

Sub-limit in health insurance is a particular sum fixed as part of your health insurance policy, spent to cover a specific health condition. On the other hand, exclusions are the healthcare conditions or situations which are not covered under your policy or may be covered after completion of the waiting period.

Do health insurance providers offer any rider facility for permanent exclusions?

No, most health insurance companies do not provide any riders with permanent exclusions

How can I get coverage for a permanent exclusion?

You cannot get coverage for permanent exclusion as most insurance companies do not offer them.

Why do insurance companies apply permanent exclusions in health insurance?

Permanent exclusions are included under health insurance policies to prevent fraud.

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Jul 18, 2023
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PayBima Team
PayBima is an Indian insurance aggregator on a mission to make insurance simple for people. PayBima is the Digital arm of the already established and trusted Mahindra Insurance Brokers Ltd., a reputed name in the insurance broking industry with 17 years of experience. PayBima promises you the easy-to-access online platform to buy insurance policies, and also extend their unrelented assistance with all your policy related queries and services.

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