What Isn’t Covered in Your Health Insurance Policy?

General Exclusions in Health Insurance Policy

Health insurance plans in India come with certain common exclusions. Hence, it is important to understand that not every health-related expense is covered under your comprehensive health insurance policy. Here are the illnesses, treatments or expenses that are typically not covered under most of the health insurance policies in India:

Pre-existing diseases and waiting period

All health insurance policies come with a waiting period initially, and for specific treatments and pre-existing diseases. Generally, the health insurance policies exclude the following during the waiting period:

• Most of the health insurance plans come with an initial waiting period of 30 days during which no claims except the hospitalisation due to accidents are entertained.
• Health insurance coverage for specific illnesses or procedures comes with a ‘specific waiting period’, which generally ranges from 12 months to 36 months. This includes diseases or procedures like osteoporosis, joint replacement surgery, cataract surgery, hernia and more. Health insurance policies specify these ailments or procedures in the policy document.
• Pre-existing illnesses like hypertension, diabetes, heart-related issues, etc, are generally covered after the waiting period, ranging from 12 months to 48 months. Some plans allow day 1 cover for listed illnesses like Diabetes, Hypertension, Asthma, etc. on payment of additional premium.

Cosmetic procedures and dental treatments

Generally, health insurance policies do not cover cosmetic procedures like plastic surgery, dental surgery, laser treatments, etc., unless it is medically needed after an accident. Routine vision, dental and hearing aid expenses are not covered.

Infertility, childbirth and maternity treatment cost

Most of the standard health insurance policies do not cover treatment costs related to childbirth, pregnancy, miscarriage and other maternity-related expenses. Most policies also do not cover infertility treatments such as IVF procedures, surrogacy and other treatments. However, employer-sponsored mediclaim policies provide coverage for maternity and childbirth. Many individual and family floater health plans offer add-ons to cover these expenses after a specified waiting period.

Unapproved and experimental treatments

Generally, Indian health insurance policies exclude coverage for unapproved drugs, experimental medical procedures and treatments that are not clinically supported. Some policies may also exclude the cost of alternative treatments – AYUSH (Ayurveda, Yoga, Unani, Siddha and Homoeopathy).

Self-inflicted injuries and alcohol abuse

Health insurance policies do not cover self-inflicted injuries, suicide attempts, alcohol or substance abuse. Some policies have limited coverage for psychiatric disorders and mental health.

Genetic health conditions and congenital illnesses

Standard health insurance policies do not cover congenital illnesses present at the time of birth (Down syndrome, cleft lip, etc.), and genetic medical conditions. However, some new policies may offer add-ons to cover them.

Treatments outside India

Standard health insurance policies do not provide coverage for treatment expenses incurred outside the geographical area of the policy, i.e. treatments availed outside India. However, a global health insurance policy may provide coverage for the same.

Sexually transmitted diseases (STDs), HIV/AIDS

Most health insurance plans do not provide coverage for treatment costs related to any sexually transmitted diseases, and HIV/AIDS

War and illegal acts

Standard health insurance policies in India do not include coverage for injuries related to illegal acts, adventurous sports/activities, terrorism and war.

Weight management and obesity

Obesity related treatment or weight management bariatric surgeries are typically covered under the standard health insurance coverage.

Understanding the policy exclusions plays a crucial role in the smooth settlement of claims. At Jio Insurance Broking, you can compare various health insurance policies after clearly understanding their scope of coverage, exclusions and cost. The platform helps you make an informed choice suitable for your insurance needs.

Tips for Smooth Settlement of Claims

Here are some key tips to avoid claim rejections at the time of distress:

• Read the policy documents carefully before buying a plan to understand the scope of coverage, exclusions, sub-limits and other terms and conditions
• Read exclusions related to the add-ons
• Understand how the waiting period works and the list of specific illnesses and treatments it is applicable to.
• Be updated about IRDAI regulations and timely changes in them.

Conclusion

To conclude, a comprehensive health insurance policy is an absolute necessity to safeguard yourself against medical uncertainties. However, it is vital to understand that the policy is not all-encompassing. There are some common exclusions, and understanding them helps you make financial planning accordingly to avoid the surprises at the time of claim and medical distress.