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What are Health Insurance Exclusions?

As healthcare treatments become more expensive, it is necessary that you take adequate measures to protect yourself from such possible financial risk. One way to handle the costs of future medical emergen
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Alok Mishra
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Alok Mishra

Insurance Writer

Alok Mishra is a Digital and Content Marketing specialist with 10 years of experience. He has spearheaded Web Content, Social Media & Branding, and Community Building initiatives to drive growth for prominent brands.

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Bhaskar Sinha
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Bhaskar Sinha

Insurance Expert

8+ years of experience in Life Insurance with expertise in Developing Life and Health Products, Digital Sales, Conducting effective trainings and Key Account Management.

What are Exclusions in Health Insurance?

An exclusion can be defined as a provision included in an insurance agreement that mentions situations which will not be covered by the insurer. So, when one or more criteria of exclusion is met, the insurance company will not pay out a claim request.

Health insurance exclusions usually refer to medical expenses like pre-existing conditions and specific procedures like dental surgery that will not be covered by the insurer. If an insured person meets the exclusion criteria specified in the health policy, any medical expenses in such cases will have to borne out of pocket by the insured without any payout being made by the health insurance provider.

In India, health insurance exclusions tend to differ from one insurer to another. Additionally, exclusions may also differ from one plan to another even when provided by the same insurer. In the following sections we will discuss some common health insurance exclusions that you must know about before you purchase a suitable health insurance plan.

List of Some Common Health Insurance Exclusions in India

There are many health insurance exclusions, however, these can vary from one insurance plan to another. The below list provides details of a few common exclusions that may be applicable to a standard health insurance plan:

Pre-Existing Conditions

One of the most common exclusions in health insurance policies include pre-existing conditions.

Before the plan's effective date, any ailment or injury you experience will be regarded as a pre-existing condition. It covers any condition for which you've had symptoms. It can also list conditions for which you had treatment during a defined timeframe before the plan's inception. It may also entail difficulties of which you are unaware. Be aware that some conditions may be categorized under health insurance exclusions even if there is a waiting period.

Vision and Dental Expenses

Ideally, insurance coverage would cover both dental and eye treatment simultaneously, but this isn't always the case. Insurance companies offer dental and vision coverage in addition to traditional medical insurance, but it often comes at an additional cost when offered as a rider. Some insurance plans may consider expenses for dental and vision-related illnesses like refractive corrections under exclusions.

Maternity Expenses

It is essential to double-check the exact wording for both maternity coverage and exclusions in health insurance, the cover offered can differ from one plan to another. While standard health plans may cover expenses for treatment of conditions like ectopic pregnancy, many pregnancy-related expenses are usually not covered. Other pregnancy-related expenses that may be excluded in health plans include medical termination of pregnancy, fertility treatment, etc.

However, by purchasing a maternity health cover, a variety of pregnancy-related expenses like natural/caesarian birth may be covered along with key pre-natal and pre-natal treatment expenses.

Cosmetic Surgery Expenses

Expenses-related to cosmetic surgery i.e. surgery not necessary for any medical purposes, is one of the common exclusions of standard health plans. However, if such cosmetic or plastic surgery is deemed medically necessary to treat a health risk due to accident, the insurer may provide coverage for such treatment. However, such treatment must be certified as medically necessary by a registered medical practitioner.

Treatment of Injuries Due to Hazardous Activities or Adventure Sports

Another common exclusion in health insurance is the cost associated with the treatment of injuries that may be a result of hazardous activities or adventure sports. Common examples of activities and sports that can be considered as hazardous include rock climbing, para-jumping, horse racing, motor racing, deep-sea diving, etc. The detailed list would be available in the health insurance policy document provided by the insurer.

What are Common Health Insurance Inclusions?

It’s important to understand health insurance inclusions before we talk about health insurance exclusions.

In India, health plans usually cover hospitalization costs, daycare procedures, pre-and post-hospitalization costs, etc. To fully comprehend the extent of your strategy, it is necessary to read the relevant policy documents. Non-medical expenses in health insurance do not include admission or registration charges. It lists the benefits you are entitled to as well as the things that your plan doesn't cover.

Below are some of the common inclusions of health insurance plans in India:

  • Individuals or families receiving inpatient treatment (hospitalization):
  • Pre and post-hospitalization expenditures
  • Hospital accommodation
  • Daycare assistance
  • Periodic health checkups
image heath_exclusion_0213f3a0db

Tips to Consider Before Buying Health Insurance

Now that we are aware of the health insurance exclusions, it’s time to buy health insurance. However, before that happens, these tips can help you take a wise decision. Even though there is no perfect formula, the following are some tips to choose health insurance cover:

Claim Process

When paying medical claims, a streamlined claim settlement procedure is a true boon. Examine the insurance provider's website, contract, health insurance exclusions and customer testimonials to determine its effectiveness.

Insured Amount

The premiums for health insurance are a breakdown of the amount insured or covered. The higher the amount covered, the higher are the premiums. In the event of a medical emergency, the additional cost for the add-on services will be worthwhile. Before you sign the contract, you need to look over the amount of insurance and make sure you understand it. Ensure that you are aware of the health insurance exclusions as well.

Network Hospitals

Numerous insurance firms currently provide cashless claim settlements. This option may seem good, but you should know that you can only use it at hospitals in the network of your insurance company. Verify with your insurance to determine whether these hospitals are close to your area. In the event of an emergency, you will not be required to drive long distances if your insurance covers a broad network of hospitals.
image heath_exclusion1_0c8497a43a

Renewal

Usually, you should acquire health insurance coverage that allows renewal. Every insurance policy has a certain length of time it can be used, and policyholders are encouraged to extend their policies so they can keep getting benefits even after the policies have run out. During renewal, you can also examine your coverage amount.

Free Checkups

Checkup costs have skyrocketed and continue to rise with each new day. Regular checkups are required and should be covered by your health insurance. Check with your insurance company to see if it covers a plan for preventive health checkups. Some insurers consider free check ups as a health insurance exclusion, so read through your health plan document carefully before making the purchase.

Health Insurance Exclusions and Inclusions

It is recommended to study your health insurance policy's inclusions and exclusions. Health policy can also be disease specific. If you don't understand how your insurance works, your claims could be denied, and you could have to pay for things you didn't expect.

Expansion Covers

Each health insurance carrier offers a selection of optional benefits. Check with your insurance company to see if the add-ons are appropriate for you and your family. For instance, if you have a spouse, you may choose to include maternity coverage.. Look for additional non-payable items in health insurance that you may want to purchase to extend the range of health insurance benefits you can avail.

While you do not need to submit or attach any documents for preventive health check-up cost or mediclaim premium paid when filing ITR, make sure you retain copies of the document. It may be required as proof at a later date in case you receive an income tax notice.

Frequently Asked Questions (FAQs)

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ARN No: June23/Bg/21U

Source:

www.irdai.gov.in/admincms/cms/uploadedfiles/Guidelines%20on%20Standard%20Individual%20Health%20Insurance%20Product.pdf

www.axisbank.com/progress-with-us/money-matters/insure/8-features-you-must-compare-before-buying-a-health-insurance-plan

jamanetwork.com/journals/jama/fullarticle/2729357

www.healthinsurance.org/glossary/exclusion/

www.livemint.com/money/personal-finance/what-are-different-types-of-health-insurance-policies-in-india-11654233086998.html

www.moneycontrol.com/news/business/7-things-to-consider-before-buying-health-insurance-4943091.html

www.irdai.gov.in/admincms/cms/uploadedfiles/Guidelines%20on%20Standard%20Individual%20Health%20Insurance%20Product.pdf

www.moneycontrol.com/news/business/personal-finance/how-much-health-insurance-do-you-need-9120541.html

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