10 most common health insurance exclusions

August 25, 2022

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exclusions in health insurance

Exclusions in Health Insurance: Having a health insurance plan always helps in times of a medical emergency. Health related issues have increased and so have medical expenses. At such times, a health insurance policy provides you with financial coverage against hospital bills. In case of hospitalization due to an illness or an accident, a health policy provides coverage to the insured up to the specified sum insured.

However, if you don’t purchase a health insurance plan reading the policy terms and conditions then you will be in for a surprise as all medical conditions may not be covered under the plan. This is because health insurance comes with a specific list of exclusions which are mandatory to check on before proceeding with the purchase. By overlooking what is missing your claim will not be supported and you will end up paying for the expenses out of your pocket. 

Being informed about the specific list of exclusions always helps as you can verify the same when filing the claim. A policyholder cannot raise a claim for conditions that are not covered under health insurance. 

Here are 10 most common exclusions in health insurance:

Pre-existing medical conditions: These are conditions that a policyholder is suffering from at the time of policy purchase. These may include cholesterol, diabetes, etc. Such pre-existing medical conditions and other conditions related to these are covered only after a period of 2-4 years. For instance, if you suffer from cholesterol and in the first year of the policy purchase, you file a claim for heart attack then in this case if the attack is caused due to high cholesterol levels, then the claim will be rejected.  Any claim filed for a pre-existing condition during the waiting period is rejected.  

Cosmetic surgery: Cosmetic procedures done to enhance the presence of the face or body are not covered. However, in case of an accident-causing major disfigurement, many insurers provide coverage for cosmetic surgeries. Hence, if you wish to undergo cosmetic surgery then you will have to arrange for the funds by yourself. 

Alternative treatments and therapies: Alternative treatments and therapies including yoga, unani, sidha, ayurveda, and homoeopathy treatments are not covered under insurance. This line of treatment is usually opted for by senior citizens and individuals looking for non-allopathic treatments. 

Self-inflicted injuries: Health insurance does not provide coverage in case of self-inflicted injuries like suicide attempt, self-medication, etc.  

Pregnancy and childbirth: Few health insurance plans do not provide coverage for pregnancy and childbirth; they also don’t provide coverage in case of abortion, infertility, etc.  

Diagnostic expenses:  Routine tests like blood test, diabetes test, etc. undertaken for diagnosis of treatment are usually not covered under health insurance. However, if the diagnosis requires hospitalization, then in this case the costs of such tests will be covered under pre-hospitalization expenses.  

Permanent exclusions: Injuries due to war, HIV, self-inflicted injuries, etc. are permanently excluded. Therefore, these conditions are permanently excluded from coverage under health insurance.  

Waiting period clause: Health insurance companies come with a waiting clause for specific medical conditions during which any claim filed for the mentioned conditions are not covered. Diseases like dengue, hypertension, etc. are covered under health insurance but only after a waiting period of 2 years.  

Dental, hearing and vision: Dental and vision procedures do not require hospitalization and hence these are not covered under health insurance.  

Lifestyle-related ailments: Hospitalization caused due to excessive alcohol or smoking is not covered under health insurance. Also, health policies for individuals with smoking and drinking habits usually come at a high premium. 

A health insurance policy provides financial coverage in case of a medical emergency. However, it is best to check on the coverage before making the purchase as the list of exclusions varies from insurer to insurer.  

Moreover, if you have employer-provided group health cover then the above features are generally not excluded as today’s modern day health plans do offer coverage for maternity, and diagnostic expenses and come with no waiting period for pre-existing medical conditions.  

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