When buying group health insurance, employers focus mainly on what is covered under the policy, overlooking the general exclusions. A group health insurance plan has a list of exclusions based on which the insurance company can deny coverage to employees and their family members. There are certain treatments and medical conditions for which the insurance company can reject the claim filed by the employee. Exclusions in group health insurance are important to be considered because they can lead to employee dissatisfaction as the employees will have to bear the medical expenses out of their pocket. Read on to know all about group health insurance exclusions.
Exclusions in Group Health Insurance: Things that are not covered
Health insurance plans come with a list of exclusions that are mentioned in the policy document. You cannot claim for any expenses that you make if the list of treatments or medical conditions is mentioned as an exclusion in the policy.
A few of the common group health insurance exclusions include dental treatments, injuries caused due to suicide attempts, pre-existing medical conditions, etc.
List of Common Exclusions in Group Health Insurance
Given below are a few of the common exclusions in group health insurance
- Lifestyle-related medical conditions: Diseases that are caused due to excessive smoking, drinking, or drug abuse are not covered. This may include lung diseases, respiratory problems, etc.
- Cosmetic treatments: Treatments that are undertaken to enhance appearance such as botox, derma fillers, chemical peels, plastic surgeries, etc. are not covered. However, if the insured is involved in an accident that causes damage to his face then, in this case, cosmetic treatments are covered.
- Injuries caused due to self-harm: Expenses for treatments caused due to self-harm activities such as suicide attempts, etc. are not covered.
- Dental, vision and hearing: Treatments related to teeth, eyes, and ears are not covered under group health insurance unless required due to an accident.
- Infertility treatments & abortion: While group health insurance does provide coverage for maternity and newborn expenses after a waiting period, it does not provide cover for infertility treatments and abortion.
Can Group Health Insurance cover pre-existing conditions?
Yes, group health insurance does cover pre-existing medical conditions. A master policy is issued in the name of the employer which automatically provides coverage to all employees. Several group health insurance providers offer coverage for pre-existing medical conditions from day one. However, each group health insurer offers different coverage and hence, it is best to check on the policy inclusions and exclusions before proceeding with the coverage.
Is group health insurance mandatory?
Earlier, prior to the COVID-19 outbreak, group health insurance was not mandatory for employees. However, recently, the government of India as well as the IRDA made it necessary for companies to offer group health coverage to employees.
What are exclusions in group health insurance?
Exclusions in group health insurance refer to the medical conditions for which the insurance company will not provide coverage. This means, for instance, if Rishi, having a group health policy of Rs. 5 lakhs requires to undergo a cosmetic treatment then, in this case, the insurance company will not provide any coverage as coverage for such treatments is not provided under group health cover. However, if Rishi meets with an accident due to which he has to undergo cosmetic surgery then in this case cover will be provided.
Guidelines on standardisation of exclusions in health insurance
IRDA, in its circular issued in the year 2019 issued a few guidelines to standardise exclusions in health insurance. Prior to this, insurance companies were not following any standard format to define the format of health insurance exclusions
- Knee replacement surgery, cataract, Alzheimer’s, etc. which were not covered are not covered
- Treatment for mental illness and internal congenital diseases are covered
- Neurodevelopment disorders, puberty, and menopause-related disorders are now covered
Permanent and temporary exclusions in health insurance
Here is a list of permanent and temporary exclusions in health insurance
Permanent exclusions in health insurance
Rest cure, respite care, rehabilitation: Expenses incurred towards hospitalisation in case no active treatment is being carried out and the insured simply wants bed rest
Obesity and weight management: Treatment or surgery is done for weight control or obesity
Investigation and evaluation: Hospitalisation is done only for observing or monitoring purposes
Gender change treatment: Treatments undertaken to change the gender that makes the insured look like that of the opposite sex
Hazardous profession or adventurous sports: Any injuries caused while working as a professional in adventure sports activities like scuba diving, river rafting, mountaineering, etc.
Unproven treatments: Expenses towards surgeries and medical procedures that are not proven to be effective are not covered.
Drugs and narcotics: Treatments carried out due to drugs or alcohol abuse are not covered
Excluded providers: Getting treated at a hospital that is excluded by the health insurance company
Outpatient expenses: OPD expenses are usually not covered under health insurance. These may include regular doctor visits, diagnostic tests, etc.
The insurance company can also include a list of permanent exclusions for which you may not be provided coverage in future depending on your medical condition. For instance, if as a child you were diagnosed with cancer, the insurance company will agree to provide you coverage based on excluding cancer coverage forever.
Temporary health insurance exclusions
When you get health insurance, you may not be able to get coverage starting from day one. Health insurance companies will ask you to wait for a certain period of time before offering you full coverage. Hence, a few conditions might be excluded from your policy on a temporary basis.
Initial waiting period: This is the time when you have just made the policy purchase and the insurance company will not provide any coverage for the first 30 days for any medical condition. Coverage will be given only in case of an accident.
Pre-existing waiting period: This relates to the medical condition you might be suffering from at the time of policy purchase. For pre-existing conditions, there is a standard waiting period of 2-4 years.
Waiting period for specific medical conditions: Every insurance company has a specific list of medical conditions for which they don’t provide coverage for at least 1-2 years. This is based on the rules of the insurance company and not your health condition.
List of diseases not covered under group health insurance
The below diseases or medical conditions are usually not covered under group health insurance:
- Self-inflicted injury
- General debility
- Naturopathy treatments
- Malignant Neoplasms
- Heart Ailment Congenital heart disease and valvular heart disease
- Inflammatory Bowel Diseases
- Chronic Kidney disease
- Cerebrovascular disease (Stroke)
- HIV & AIDS
- Alzheimer’s Disease, Parkinson’s Disease
- Hepatitis B
- Loss of Hearing
- Papulosquamous disorder of the skin
- Avascular necrosis (osteonecrosis)
Pre-existing condition exclusion period definition
Pre-existing medical condition refers to the medical condition that the insured individual is diagnosed with at the time of policy purchase. This may include conditions like diabetes, cholesterol, thyroid, etc. Insurance companies do not offer coverage for such medical conditions instantly and instead cover these and their related medical conditions only after a waiting period of 2-4 years.
Can a group health insurance exclude pre-existing conditions?
No, group health insurance coverage generally does not exclude pre-existing medical conditions and instead offers coverage for the same from day one. Certain group health insurance providers may cover pre-existing conditions after a waiting period of 2-4 years.