10 Common Exclusions in a Health Insurance Policy

With changing lifestyles, there is a surge in health-related issues which is why health insurance is vital in today’s times. A health insurance policy offers financial protection at the time of medical emergencies by covering hospital and other medical bills. Health insurance is an agreement between you and the insurer to pay for your hospitalization and medical expenses as per the policy terms.

While everyone must be secured with a health insurance policy, merely buying one is not adequate. You need to ensure that you are buying the best health insurance that is available to you. Your purchase must be smart and objective to avoid disappointments in the time of need. While most people take a keen look at what is included in the health insurance plan, they seldom ask for exclusions. While a health insurance policy covers many illnesses and procedures, certain treatments and medical conditions are not covered by the policy. These are known as policy exclusions.

Understanding health insurance exclusions

Health insurance exclusions are illnesses and treatments that are not a part of health insurance agreements and hence, the insurer does not offer coverage for the same. These exclusions are mentioned in the policy contract. Hence, it is vital to read the document carefully.

Often many policyholders get shocked and disappointed to know that an expensive treatment they were looking for is not covered in their best health insurance policy. Staying informed of the exclusions and inclusions before making the policy purchase can help you plan the treatments better. While these exclusions may vary from person to person, it is still important to know and understand them so that you get the best health insurance as per your needs.

Exclusions in a health insurance policy

1. Dental, vision and hearing-related treatments: While some policies may offer an exception here but dental and vision treatments are not covered by the health insurer. This is because these do not require hospitalisation. Exceptions can be made in cases when a serious procedure requires hospitalization and hence, it is best to check the same with your health insurance policy provider. There are also options to opt for these benefits as an additional add-on to your health insurance policy.
2. Maternity and childbirth: These expenses may or may not be covered by the insurance company. Many insurance providers offer this benefit after a waiting period of a few years. Maternity expenses can burn a huge hole in the pocket. But in case your policy does not offer the coverage you can buy it separately as a rider. Maternity insurance rider offers coverage for normal and C-section deliveries, pre and post-natal expenses, newborn cover, termination of pregnancy due to complications and much more.
3. Cosmetic surgery: Cosmetic surgery is performed to reform or enhance a part of the body. Any procedure as a part of a cosmetic procedure is not covered by the health insurance policy. Those who wish to undergo cosmetic surgery must arrange funds on their own for the same. However, many policies may cover cosmetic surgeries if the same is required due to disfigurement from a major accident.
4. Therapies and alternative treatments: Many follow-ups and additional treatments like physiotherapy may not be covered under the health insurance policy. Many insurance companies also do not cover alternative treatments like Naturopathy, Ayurveda etc. It is suggested that this exclusion be verified by the policyholder before purchasing the policy.
5. Treatment for pre-existing diseases:Many health insurance companies have a waiting period for pre-existing diseases. If you wish to undergo treatments for the same, it is better to check the coverage and duration of the waiting period at the time of purchasing your health insurance policy.
6. Self-harm or self-inflicted injuries: Injuries due to intentional harm like cutting yourself, drug overdose or suicide attempt are not covered under the health insurance policy.
7. Joint replacement procedure: Joint replacement surgery is one of the most common surgeries that people go for nowadays. The requirement for this surgery may arise due to ailments and old age. However, most health insurance policies do not offer coverage for joint replacement surgery and the expenses need to be borne out of our own pocket.
8. Mental health conditions: Today’s fast-paced lifestyle, global pandemic, as well as increasing peer pressure, have given a rise to mental health conditions like anxiety and depression. These may require a person to undergo medical treatment, including therapies. However, most health insurance policies do not cover mental health issues.
9. Permanent exclusions: There are certain situations and medical conditions that are permanently excluded from all health insurance plans. For example, congenital diseases, damages due to nuclear weapons, emergency issues due to war etc. additionally, sexually transmitted diseases like AIDS are also never covered by health insurance policies.
10. Specific expenses: Even the best health insurance policy may cover most of the treatment costs, there are certain expenses that you may have to bear out of your own pocket. These expenses vary from policy to policy and can be lab tests, ambulance charges, doctor’s fees, or a sub-limit on room rentals. You may also have to bear the cost of consumables. These expenses must be verified by you with the insurance provider as the clause may vary from policy to policy.

While a health insurance policy offers financial coverage in case of medical emergencies, it is vital to understand that your policy may have certain limitations. It is hence a good idea to understand and be thorough with both inclusions and exclusions of your policy before you make the purchase. Make sure you read your policy documents thoroughly to understand the extent and nature of your coverage.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.