Every health insurance company provides a list of exclusions under their health insurance plans that are in adherence to the guidelines given by the Information Regulatory and Development Authority of India (IRDAI). The insurer can reject your claims arising for hospitalization related to the specific list of diseases that are not covered by health insurance.
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Therefore, it is suggested that you do your research and planning before selecting a health plan. It will help you choose a health insurance policy that has minimal exclusions and offers maximum coverage. Furthermore, medical insurance plans would generally exclude certain illnesses from the first year of coverage and cover it after the waiting period is over.
There are a certain standard sets of exclusions like the cost of contact lenses, spectacles, and hearing aids that are not covered. Also, dental surgery/ treatment ( unless requiring hospitalization), congenital external defects, convalescence, venereal disease, general debility, use of intoxicating drugs/alcohol, Self-inflicted injuries, AIDS, diagnosis expenses, infertility treatment, and Naturopathy treatment make a list of exclusions under health insurance plans in India.
Read to know more about the list of diseases/treatments that are not covered under a health insurance plan:
Cosmetic surgeries like Botox, Liposuction, implants and similar surgeries are excluded from a health insurance policy. You can check with your insurer if you plan to undergo any such surgery during the policy term. Unless it is a part of the treatment, insurance companies do not compensate for such medical procedures.
Pre-existing diseases and related waiting periods vary from one insurance company to another. Some insurance providers may provide cover for diabetes, blood pressure, heart patients, etc. Most of the health plans would include such expenses only after the waiting period is completed, which can range from 12 months to 48 months. However new health plans are being launched that provide PED cover from Day 1.
And in some case, the insurer will cover pre-existing diseases on payment of additional premium.
Hospitalization expenses related to infertility/pregnancy complications like abortions are excluded from health insurance coverage. In some maternity health plans, these expenses can be covered, but in basic health plans, these expenses are not covered. You can check your policy wordings if you specifically looking for coverage for pregnancy-related expenses. You can also check out women specific health plans to cover such expenses.
Under your health insurance policy, the insurer does not provide financial cover for health tonics and supplements. If these are recommended by the treating doctor then the expenses might be claimable. But if you are taking it without any prescription then it shall not be a part of policy coverage. For details, you can refer to the policy wordings.
If any illness is tracked to overconsumption of alcohol like liver damage, and other problems, then the insurance company holds the right to reject your health insurance claim.
Any expenses that you incur on alternative therapies like naturopathy, acupressure, naturopathy, acupuncture, reflexology, and similar expenses are excluded from health insurance coverage.
Any expense incurred on diagnostic or pathological services like scans, blood tests, and other body tests performed at a nursing home or hospital are excluded unless the policy covers them specifically or it is required as a part of the treatment.
These were some of the common exclusions that you will have to bear on your own. Let us help you understand better with an illustration:
After spending 5 years of togetherness, Amita and Yash decided to plan a kid. Soon, Amita was got diagnosed with infertility issues that required her to undergo surgery as per her obs/gynecologist. She had no prior knowledge that her health insurance excludes the treatment. And she had no maternity or specific women health insurance plan that would include such costs.
The claim rejection came as a disappointment to her and her husband. And, Yash and Amita had to pay for the treatment cost from their pocket. Later, she came to know that her infertility treatment was not covered under her health insurance policy. Had she read the policy wordings properly or knew about it she could save herself of the disappointment and could have looked for another health insurance plan from another insurer that would offer some provision to cover it.
For any such details, you can speak to our health experts or chat with us online and we will get back to you with the best solution within your budget.
So, to avoid going through such a negative experience and manage your finances better, read your policy wordings till the end to have better clarity on both the inclusions and. the diseases that are excluded from health insurance scope of coverage.
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