Common Health Insurance Exclusions

Navigating Health Insurance Exclusions: What to Expect

When your Health Insurance claim gets rejected, you might feel disturbed. This happens when you have no idea what your Health Insurance policy covers (Inclusions) and does not cover (Exclusions). Health Insurance policies have certain Exclusions which you must know before purchasing a plan.

What are exclusions in health insurance?

An exclusion in health insurance refers to a medical procedure or condition that is not included in or covered by the policy. There may be some common exclusions in health insurance policies.

What do you mean by “Exclusions” in Health Insurance?

“Exclusion” can be a medical condition or a healthcare expense that is not covered under your medical insurance policy. This indicates that your insurance company won’t cover it.

People are always interested in what the health plans offer and need to check what the policy does not cover. That’s why you must always read the policy wording before you sign the policy document.

There are certain Exclusions to your Health Insurance, which you need to be aware of.

Time Bound Exclusions

Time-bound exclusions are nothing, but the healthcare costs or medical expenses incurred that do not get covered by your Health Insurance plan for some time. Pre-existing diseases, specific diseases, Initial Waiting Period & pregnancy and related conditions all fall under time-bound exclusions. To fully grasp the scope of your coverage, it's essential to understand all health insurance exclusions in your policy, as they include time-bound limitations such as waiting periods.

Also Check: Comprehensive Health Insurance Plan

i. Pre-Existing Diseases (PEDs) Waiting Period

Pre-existing health issues should be disclosed while purchasing a Health Insurance policy.
A waiting period of 12/24/36 months is applicable for a PED, depending upon the policy. On the completion of the specified Waiting Period, such PEDs are covered. Understanding the specific waiting periods is key to navigating the common health insurance PED exclusions related to pre-existing conditions.

ii. Specific disease Waiting Period

The majority of insurers provide coverage for certain conditions after a 24-month waiting period from the commencement of the policy.

iii. Initial Waiting Period

Except for claims stemming from accidents, which are covered if they occur within 30 days of the policy’s first commencement date, medical expenses for any disease must be excluded from coverage.

iv. Pregnancy and related conditions

Maternity benefits may not be covered under some standard Health Insurance policies. In order to get this coverage, you may need to contact an insurer and inquire about the availability of a specific policy or an add-on. However, pregnancy is covered in some Health Insurance plans but only after a certain Waiting Period. Some insurers cover infants and newborn babies with a Waiting Period of 90 days.

Permanent Exclusions

Permanent Exclusions are those listed categories of treatments and ailments which are never covered under a Health Insurance policy. They are excluded permanently. Even some policies may have permanent and temporary exclusions. So, check once or twice before you buy your health insurance. Being aware of the standard permanent exclusions in health insurance will help you manage your expectations regarding future claims and out-of-pocket costs. Being aware of the standard permanent exclusions in health insurance will help you manage your expectations regarding future claims and out-of-pocket costs.

Dental, Ophthalmic OPD treatment

Dental and ophthalmic OPD treatments are covered under some Health plans. Most of the time, these procedures do not need any hospitalisation.

Lifestyle-oriented diseases

Lifestyle-related disorders/ailments are excluded or covered with higher Premiums under Health Insurance policies. One such illness that is excluded is lung disease brought on by smoking or cirrhosis brought on by drinking alcohol.

Cosmetic procedures

An increasing number of people prefer cosmetic surgery to improve their appearance. Health Insurance does not cover all cosmetic procedures. Plastic surgery can, however, be covered in situations of accident or injury where it is necessary.

Infertility and Assisted Reproduction

Treatments such as IVF (In-Vitro Fertilisation), IUI (Intrauterine Insemination) and other assisted reproductive technologies are excluded from most base plans unless a special rider is offered.

Congenital Disorders

Treatments related to congenital (birth) defects, both internal and external are commonly excluded unless the insurer offers special riders.

Also Read: Critical Illness Multipay Insurance Policy

Diagnostic expenses

Health Insurance policies usually will not cover the costs of unproven or experimental treatment. The insurance will cover the charges if the imaging or lab test shows a positive result for any disease or injury that necessitates hospitalisation.

Injuries caused by suicide attempts or Self-inflicted injuries

Health Insurance plan does not provide coverage for wounds sustained during suicide attempts or other self-harm.

Conclusion

Exclusions are the services that are not covered by your Health Insurance plan. This implies that you need to pay for these costs out-of-pocket.

Therefore, before choosing a policy, you should carefully read the policy document to ensure that you fully understand the Inclusions, Exclusions and limitations of the policy to avoid the unpleasant situation of your claims being rejected. You can choose your health policies after knowing the exclusions.