Exclusions in Health Insurance

Imagine that you file a claim under your health insurance policy and your insurer comes back to you saying that your claim is not payable as your condition is not covered under your policy. It sounds nasty, right? But this can happen to you if you are not aware about the exclusions under your health insurance plan. So to not get the shock of your life and know what is not covered under your policy, you should read your health insurance policy document completely.

Each health insurance plan comes with its own set of exclusions. Some of these exclusions are common across health insurance plans while some others are specific to the policy. Here are some exclusions which are commonly found in health insurance policies.

[1] Time Bound Exclusions in Health Insurance or Waiting Period

Waiting period in health insurance refers to the time period before which certain conditions are not covered under your health insurance policy. Your policy starts covering these conditions only after you serve the waiting period fully.

In case you raise a claim for a condition within the waiting period, your health insurer can reject your claim. There can be multiple waiting periods under your health insurance policy. Let’s understand them.

1. Initial Waiting Period: All health insurance plans usually come with an initial waiting period of 30 days. You do not get cover under your policy for the first 30 days from the time your policy starts except if you are hospitalised due to an accident. 
2. Waiting Period on Specific Illnesses: Most health insurance policies in India impose a waiting period of 24 months on certain illnesses. These are slow growing illnesses for which the treatment can usually be planned well in advance. These illnesses are listed in your policy document and cover on these illnesses starts only after you serve the initial waiting period of 24 months.
3. Waiting Period on Pre-Existing Conditions (PEDs): Any health condition which exists before you take your health insurance policy is termed as pre-existing condition or pre-existing disease (PED). Health insurance plans impose a waiting period on PEDs before the cover on them becomes active. Waiting period on pre-existing conditions can range from 24 to 48 months depending on the health insurance plan you choose. Some health insurance plans now offer add ons to reduce the waiting periods on pre-existing diseases. These can be great add-ons for people with pre-existing diseases who are looking out for new health insurance cover. In certain cases, your health insurer might choose to completely deny to cover your pre-existing condition. This is permanent exclusion and your policy will never cover your pre-existing condition.
4. Waiting Period on Maternity Benefits: Some health insurance plans come with inbuilt maternity benefits with a waiting period before these benefits become active. This waiting period can range from 9 months to 4 years depending on the health insurance plan.
5. Other Waiting Periods: Health insurance plans can come with some complimentary benefits which are usually not covered under health insurance policies such as OPD benefits or dental benefits. And there can be a waiting period of 2 or 3 years before these benefits become active. 

[2] Permanent Exclusions

Some exclusions in health insurance policies are permanent in nature. This means that your policy never covers them and nothing can change that fact. These are bonafide exclusions and health insurers across the industry impose such exclusions to manage their risks and increase financial security.

Here are some of the common permanent exclusions most of the health insurers in India impose. The list is not exhaustive and you should always go back to your policy document to find out all the permanent and other exclusions under your health insurance policy.

1. Investigation and Evaluation, and Rest and Rehabilitation:  Your health insurance policy does not cover your medical bills if you are hospitalised only for investigative and evaluative purposes or for rest or rehabilitation. Your health policy covers the costs only when you need hospitalisation for a medical treatment necessitated by an illness, injury or accident.
2. Treatments Related to Obesity or Plastic Surgery: Health insurance policies usually do not cover any treatment or surgical costs related to obesity or plastic surgery. These are usually categorised as cosmetic procedures done for beatification purposes. However if such procedures are rendered necessary due to an illness, injury or accident, your health insurance policy should cover them.
3. Gender Change: Any treatment related to change in gender is not covered under health insurance. 
4. Refractive Error: Any treatment received due to refractive index error for the correction of eyesight through a corrective surgery is not covered. However, health insurance policies cover this medical condition only in extreme cases where refractive index is 7.5 diopters or more which is not the case with most people having this condition. 
5. Unproven Treatments: Any treatment for which sufficient documentation is not available on the efficacy of the treatment for an illness might not be covered under health insurance.
6. Alcoholism, Drug or Substance Abuse: Health insurance policies do not cover any treatment which is necessitated due to alcoholism or substance abuse. If you smoke, or consume alcohol or drugs, and end up in a hospital needing treatment caused by such habits, your health insurance policy will not cover your treatment.
7. Hazardous or Adventure Sports: Your health insurer might not be keen on covering your treatment in case it is due to an injury caused during your participation in any hazardous or adventure sports. So you can either stop participating in such sports or be cautious while participating about the safety measures. 
8. Breach of Law with Criminal Intent: Your health insurer refuses to provide you cover if you sustain any injuries while you willfully participate in an unlawful or criminal activity.
9. Injuries Sustained during War or War Like Situations: Health insurers do not cover any injuries caused during war (declared or undeclared) or war-like situations such as riots, coups, usage of mass biological or chemical weapons etc.
10. Attempted Suicide: Most obviously, health insurance policies do not cover any injuries caused due to attempted suicide or self injury.
11. Medical Practitioner Outside His Discipline: If you take modern medicine treatment from a medical practitioner qualified in alternative medicine such as ayurveda, your health insurer will refuse to cover your treatment. Make sure you reach out to the rightly qualified doctor for any treatment.
12. Blacklisted Hospital: Insurers blacklist some hospitals based on their past experience of inflated or fake health claims. If you take treatment in any of these blacklisted hospitals, your claim will not be paid by your insurer. Make sure that you check the list of blacklisted or excluded hospitals from your health insurer.
13. Permanent Exclusion on Pre-Existing Disease (PED):Your insurer can also impose permanent exclusion on any of your pre-existing conditions instead of just a waiting period of a few years. This will depend on your pre-existing condition, its severity, time since its onset, current medication etc. This is subject to underwriting based on the information you provide to your insurer.

Summary

1. Health insurance policies cover the cost of inpatient patient care while you take treatment in a hospital and hence provide you protection against unexpected medical bills.
2. However, all health insurance policies come with certain exclusions. These exclusions are conditions or situations under which your health insurer does not cover your treatment.
3. Certain exclusions are time bound and come in the form of waiting periods. Once the waiting period is over, cover on the condition becomes active under your health insurance policy. These can include initial waiting period, waiting period on pre-existing conditions, waiting period on slow growing illnesses etc.
4. Some other exclusions are permanent in nature. Your health insurance policy will never cover these conditions no matter what. 
5. Permanent exclusions include hospitalisation for investigative purposes or rest and rehabilitation, cosmetic treatments, unproven line of treatments, alcoholism or substance abuse, self injury or attempt to suicide, war or war like situation etc.
6. Other than these, your health insurer can impose permanent exclusion on pre-existing conditions subject to underwriting. 
7. It is always good to know what is not covered under your health insurance policy to ensure that you do not get any shock at the time of claim. Reading your policy document carefully can help you understand the exclusions and their implications at the time of claim.

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