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10 Common Exclusions in Health Insurance Plans

21 December, 2018

Due to a change in lifestyle, health related issues have not just increased, but have become more complex in nature. Thus, it is important to have a health insurance plan in place. Health insurance is a type of insurance policy that lends financial protection during medical emergencies by paying our medical-related bills. It’s an agreement between you and your insurance company, where the insurance company pays for your medical expenses and hospitalization.


If health plans are not purchased in a smart and an objective manner, you may be in for a nasty surprise in the future. As is the case with many purchases, we tend to delight in what we are getting out of the purchase, while overlooking what is missing. This is especially true in the context of health care policies. Most people take a detailed look at the inclusions, but often fail to check the exclusions. Though health insurance policies generally cover most illnesses, but there are certain kinds of medical conditions that are not covered. These are called as health insurance exclusions.


Policyholders are often disappointed and distressed when they learn that their expensive dental treatments or cosmetic surgery procedures are not covered in their health plan. It helps to stay informed about common exclusions in policies, so that you can verify the inclusion or exclusion of the required features before you make a purchase. One needs to be very mindful while going through the exclusions otherwise they may end up facing trouble during the process of claim settlement. Although, exclusions vary from one person to another, thus there are certain exclusions in health insurance policies that you need to look at –


1. Pre-existing medical conditions

If you suffer from any health issues, it is important that you declare the same, while purchasing medical insurance. All such pre-existing conditions are covered at the end of a specified lock-in period, ranging between 2 and 4 years from the purchase date.


2. Alternative therapies

Most insurance companies do not provide coverage for the use of alternative therapies to treat health conditions. This is primarily because determining the exact coverage for such therapies is difficult as many alternative treatments are unregulated and various specialties like Ayurveda, Naturopathy, and Unani have different costs. Health insurance policies do not cover therapies such as magnetic therapy, naturopathy, acupressure, and other treatments.


3. Lifestyle related conditions

Diseases that relate to the lifestyle of the insured are excluded under health plans, unless the purchasers have paid a higher premium amount. A few such diseases include lung disease that is caused due to smoking or cirrhosis resulting from the consumption of alcohol.


4. Cosmetic treatments

An increasing number of people use cosmetic treatments to enhance their appearance, but these treatments are not covered by health insurance companies. However, medically recommended procedures such as plastic surgery to treat an accident or injury will be covered. Dental treatments are also excluded from a health plan’s coverage, as these are considered to be cosmetic in nature.


5. Pregnancy and childbirth

Several health plans do not provide coverage for childbirth and pregnancy related expenditure. Similarly, costs for treating infertility and abortion are not covered under these insurance policies.


6. Diagnostic expenses

Imaging or laboratory tests that are routinely conducted for a diagnosis can be quite expensive, but these are not covered under health policies. If the tests yield a positive result for any illness or injury that requires hospitalization however, the insurer will cover the costs.


7. Dental, hearing, and vision


Both dental and vision procedures are not covered under your health policy as they do not need any hospitalization. But when there’s a need for hospitalization, it has to be covered. Thus, you need to check this with your health insurance provider. Although, such benefits can be bought as additional riders in your health insurance plan.


8. Injuries caused due to suicide attempt

Injuries that are caused due to any kind of self-harm or suicide attempt are not covered under your health insurance plan. A policyholder will not be covered if the person harms himself deliberately.


9. Waiting period clause

Every insurance company has a general waiting period after which, one can use all the benefits of the policy. Before investing in an insurance policy, one needs to keep in mind its waiting period. The insurance market has different waiting period in a health plan that spans from:


  • 2-4 years for pre-existing diseases
  • 1-2 years for conditions like osteoporosis, hernia, and ENT related disorders
  • 90 days for infants and new born babies
  • 2 years for medical conditions such as spinal disorder, joint replacement, internal tumors, cysts, polyps, cataract, tonsils, etc.


10. Permanent exclusions


Injuries due to war, HIV, intentional injuries, congenital diseases, and others are permanent exclusions. Thus, it is important for you to read the fine print carefully before signing up for a health plan. Moreover, you can ask your insurance company about the exclusions so that you can address your queries.


Exclusions are the services that are not covered under health insurance plan. This means one has to bear these expenses from their pockets. So, in order to save yourself from such unpleasant surprises, individuals should read the policy document carefully so as to ensure that they completely understand the inclusions, exclusions, and limitations of the policy before choosing the policy.


Royal Sundaram General Insurance Company – Lifeline Medical Insurance Plans and Arogya Sanjeevani Policy provides comprehensive medical coverage plans. Royal Sundaram’s health policies are also affordable and customizable, suiting the needs of every type of customer.