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Do You Know What Your Health Plan did not Cover?

By Vikas Chandra Das
21 July 2022, 11:46 AM
do you know what your health plan did not cover

Every health plan has certain exclusions which means that the health insurance policy does not provide cover for certain aspects. As a policyholder, you must be aware of the exclusions of the health insurance policy to avoid any financial plight during medical emergencies. This is feasible only when policyholders read their policy documents thoroughly. Thus, you as an informed person must be aware of your health insurance plan exclusions before purchasing the same, instead of hurrying with the process of purchase. Exclusions are not standard for all health insurance plans and might differ from one insurance provider to another. 

Common Exclusions that Every Policyholder Should Know Before Purchasing a Health Insurance Policy

1. Pre-existing conditions

When an individual is already suffering from some ailments at the time of purchase of health insurance policy then it is known as pre-existing conditions. Usually, health insurance policies do not provide cover for the pre-existing conditions as the risk involved is high in these cases. 
However, many insurance providers would provide cover for pre-existing conditions after a waiting period of 2 years- 4 years. This waiting period varies from one insurance provider to another and the risk involved in the ailment.

Tip: So, if you have a PED (pre-existing disease), you must know the PED coverage and the waiting periods for the same before applying for the plan.

2. Pregnancy-related conditions

There are several conditions related to pregnancy such as regular health check-ups, childbirth, abortions, or any other complications during pregnancy that are not covered under health insurance. However, some health insurance providers do provide cover for pregnancy-related health conditions but only with a particular waiting period. 

Tip: So, if you are planning your child or might plan in the next few years, you must read and be aware of the waiting period associated with this before the final purchase of the policy. 

3. Regular waiting clause 

Certain ailments like gall-bladder stone operation, cataract, joint replacement surgery, etc. are usually not covered for the initial 2 years of the policy. For regular illnesses, there is a waiting period of 30 days before which claims are usually not admitted. However, accidental claims are admitted from day 1 and there is no waiting period for those.

4. Cosmetic surgeries

Usually, cosmetic surgeries are conducted to improve the look and appearance of a person. These surgeries cannot be considered as medical emergencies and are generally not covered under medical insurance. 
Tip: However, if cosmetic surgery has been recommended by a specialist due to physical damages caused because of an accident or an injury, then it can be covered by the health insurance policy.  

5. Alternative treatments

Many people resort to other alternative means of treatment when they do not obtain relief from the regular course of allopathic treatment. These other forms of alternative treatments would include Ayurveda, Naturopathy, Acupressure, Magnetic therapy, Homeopathy, etc. These alternative forms of treatment are sometimes not covered under health insurance plans.  
Tip: So, if you believe in any alternate therapy, then you must opt for a health insurance plan which covers AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homeopathy). 

6. New or advanced treatment procedures

Health insurance providers will generally take some time to keep pace with the new and advanced technologies used in treatment. Those treatment procedures, like robotic surgery, although very popular, are unproven or are still in the experimental stage. Such treatments are often not based on the established medical practices, and might not be included in the cover provided by the medical insurance plans.

7. Diagnostic expenses

Hospitalisation without any treatment, i.e. only for diagnosis purposes might not be covered under all health insurance plans. So, only if you are hospitalized and there is a proper protocol for the treatment of the ailment for which you have been admitted is followed, your claim would be admitted and processed. The claim amount would be according to the terms and conditions of your health insurance plan. 

However, if no proper treatment is done, then the diagnostic tests might not be covered under your health insurance plan.  

8. Lifestyle ailments

Due to increased bad lifestyle habits amongst people in today’s age, lifestyle diseases are on a rise. Ailments such as Cirrhosis or lung diseases which are caused due to excessive drinking or smoking are not covered under the health insurance policies. So, many health insurance plans might exclude these lifestyle illnesses to provide a competitive price for your health insurance plan.  

Tip: However, cover for these ailments can be availed by paying an additional health insurance premium. Alternatively, there are some plans, which definitely offer coverage to all ailments, irrespective of its cause.

9. Attempt to suicide and intentional harm

If injuries are caused to an individual due to an attempt for suicide or intentional harm they might not included under the scope of the health insurance policy. 

10. Limit on hospital costs or sub-limits

Many medical insurance plans come with an upper limit on several expenses such as the ambulance costs, rent of the room, resident doctor’s expenses, etc. These are called sub-limits.

For example, if the health insurance policy purchased by an individual covers a room rent of INR 5000 per day but the room rent in the chosen hospital is INR 7000, then the entire health insurance claim amount would be paid in proportion to the eligible amount (i.e. 5/7th) except some expenses like medicines, etc. 

Tip: The new-age health insurance plans usually do not have sub-limits, especially if the coverage is high. So, choose accordingly. 

11. Treatments related to dental, hearing and vision

Any expenses incurred in dental, hearing, or vision treatment procedures are not covered under health insurance policies as these procedures do not need hospitalization. 

Tip: However, if hospitalization is necessary then it could be covered, if the same is necessary and not cosmetic in nature. So, you as a policyholder must discuss this with your insurance provider on the same and whether it can be included even with additional premium. 

12. Permanent exclusions

Some cases can be considered as permanent exclusions and are not covered under most medical insurance plans such as injury from war, HIV-related ailments, congenital diseases, etc. 

Conclusion

Hence, every health insurance policy has its limitations and every policyholder has different health conditions and requirements. For an individual, choosing a health insurance policy that covers his requirements is nothing less than an art. Therefore, you must read the policy documents carefully, understand the inclusions and exclusions before purchasing the medical insurance plan.

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