Exclusions in a Health Insurance Policy

What does a health insurance policy not cover i.e exclude?

The moment of truth in an insurance policy is at the time when a claim arises. One of the most common reasons for a health insurance claim not being paid by an insurance company is when they say that the particular disease is not covered by the policy and is an "exclusion". It leaves a bitter taste in the mouth of the policyholder and can sometimes put the policyholder in great financial difficulty. Thus, it is very important to know in detail about the exclusions in a health insurance policy before purchasing it. In our opinion, it is a far more important variable than price. A policy might be 10% cheaper than a competitor's policy but might have many more exclusion clauses-in such a case, the policy with the lesser number of exclusion clauses would be the better choice for the policyholder.

In this article, we deal with some of the common exclusion clauses in a health insurance policy. Of late, we are seeing some innovation in this area with the new companies not excluding certain ailments which had traditionally been within the exclusions area

1. Maternity: In most cases, maternity and maternity related expenses are not covered in an individual or family floater health insurance policy. Maternity is typically covered in a group policy. In certain cases, we are seeing maternity being covered after 5 years into the policy.


2. Diseases or illness contracted within the first 30 days of the policy. The insurance company does this to safeguard itself against customers buying a policy immediately after a disease has been detected


3. Cataract, Prostrate, Hernia, Piles, fistula, gout, rheumatism, kidney stones, tonsils and sinus related disorders, congenital disorders, drug addictions, non allopathic/alternate treatments, self inflicted injuries, hysterectomy, fertility related treatments, etc are normally not covered under a health insurance policy. Dental treatment and cosmetic surgery is also typically excluded. Contact lenses cost is also not covered. HIV/AIDS is excluded, which has been a subject of great debate and criticism in the last few weeks. Some insurance companies do not cover treatment incurred outside the country, so you should check once before buying the policy


4. Pre existing diseases are not covered in a health insurance policy. Preexisting means a disease that you have had prior to joining a health insurance policy. The policyholder may or may not have been aware of the pre-existing disease. Further complications which arise due to the preexisting disease are also not covered. For example, renal problems which arise due to a person having diabetes at the start of the policy would not be covered. This can sometimes lead to a lot of confusion and heartburn. Someone gets admitted for a kidney related treatment, and the insurance company turns down the claim saying the kidney problem has arisen because the patient had diabetes, and rejects the claim. It can get a little grey here as medical science cannot sometimes clearly pinpoint the root cause of a particular disease outbreak. In most cases, preexisting diseases are covered after 3 or 4 consecutive policy years. This is the single biggest reason why one should buy a health insurance policy at a young age, and continue with the same insurer. Because if you shift to a new insurer, you lose your previous credit and a disease that was being covered by the old insurer might be treated as a pre-existing disease by the new insurer. We have noticed that insurance companies start facing more claims from the health insurance customers from their 4th or 5th policy year, as pre existing begins to get covered and the profitability of the portfolio goes down


5. Most policies do not cover day care, but a few like Max Bupa cover daycare, although the premium is higher in this case


6. War related health insurance claims are mostly excluded from the policy coverage


7. Abortion related health expenses are not covered in a health insurance policy

Pl do note that with competition heating up, some of the exclusions mentioned above will begin to get covered by a company or two so that it can be used as a selling point. Thus, the lists mentioned above are subject to change. The moot point here is that 10 minutes spent to read the exclusions list of the policy you are considering to buy could save you a lot of headache buyer. Be an informed buyer- there will be no else to blame but yourself.