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Major exclusions in a health insurance policy | Health Insurance FAQ #32

Last Updated: Nov 29, 2018 | 4,211 Views
So there are quite a few points to know about what is not covered in a health insurance plan. Best to understand them better before taking the plan. You will then have no unpleasant surprises. Let me try to categorise them so that it is easy to understand.

1. Exclusion for the 1st 30 days

Most health insurance plans will not cover any treatment costs of any illness in the first 30 days from the date of inception of the policy. Of course, if the hospitalisation is due to an accident, the policy will cover the treatment costs.

2. General Exclusions

These treatment costs are those which will never be covered under the policy. The ones listed below are some of the common general exclusions in a health insurance policy:
  • Naturopathy treatment, acupressure, acupuncture, magnetic and such other therapies
  • Cosmetic, obesity related treatment
  • Treatment taken outside the country
  • Unproven or experimental treatments
  • Sterility, venereal diseases or any sexually transmitted diseases
  • Dental treatment unless due to accident
  • Any case directly or indirectly related to criminal acts
  • Refractive error correction, hearing impairment correction
  • Substance abuse, self-inflicted injuries, STDs and HIV/AIDS
This list may vary from policy to policy, so best to refer to the policy wordings of the plan to know the exact details.

3. Exclusions for a fixed number of years - 2 to 3 years

Do not confuse this with the waiting period of pre-existing diseases. Health insurance plans may have a period of time for which certain illnesses will not be covered even if they are not a pre-existing illness. After the waiting period, these illnesses will be covered unless they are pre-existing in nature. Below mentioned are some of the ones which are usually part of the list:
  • Cataract
  • Benign Prostatic Hypertrophy
  • Myomectomy, Hysterectomy unless because of malignancy
  • All types of Hernia, Hydrocele
  • Fissures &/or Fistula in anus, hemorrhoids/piles
  • Arthritis, gout, rheumatism and spinal disorders
  • Joint replacements unless due to accident
  • Sinusitis and related disorders
  • Stones in the urinary and biliary systems
  • Dilatation and curettage, Endometriosis
  • All types of Skin and internal tumors/ cysts/ nodules/ polyps of any kind
  • including breast lumps unless malignant
  • Dialysis required for chronic renal failure
  • Surgery on tonsils, adenoids and sinuses
  • Gastric and Duodenal erosions & ulcers
  • Deviated Nasal Septum
  • Varicose Veins/ Varicose Ulcers
Again, please refer to the Policy Wordings of your policy to know the exact applicable list.

4. Waiting period for a fixed number of years for pre-existing illnesses

At the time of application, insurance companies will ask for any pre-existing illness or health condition which you have. These illnesses will not be covered for a specific period of time. The period of time may vary from 3 to 4 years in most policies. In some policies, it may be for a longer period of time. After the waiting period is over, the treatment for those conditions will be covered.

5. Permanent Exclusions of Pre-existing conditions

Apart from the General Exclusions, sometimes insurance companies may put a permanent exclusion clause for some of your pre-existing conditions. This is usually done in case, the pre-existing conditions is severe in nature. In such a scenario, your health insurance plan will not pay for any treatment for that illnesses and its related conditions.

I hope this was useful In case you have any questions related to this topic, do comment below and we will get back to you.

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