Your Health Insurance Policy Doesn’t Cover That!
The biggest surprise you can get at the time of a health insurance claim is to be told - “your policy doesn’t cover this condition - you’ll have to pay for it!” It’s easy to feel betrayed by the insurance company, when you suddenly learn about such ‘exclusions’ - after you’ve invested in that policy for many years.
But - there’s an easy and sure-shot way to avoid such surprises. Educate yourself about everything that’s covered by your health insurance policy - and more importantly, everything that isn’t.
So - here’s all you need to know about exclusions or situations that your insurer won’t pay for, in health insurance.
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Illnesses or conditions that your policy will never cover come under permanent exclusions - every policy will clearly list all such situations. You should go through this list in detail, before making the purchase.
Permanent exclusions are of two types -
1️⃣ Standard permanent exclusions
These are exclusions that are applied to most general health insurance policies. Here are some standard permanent exclusions you should watch out for -
- General exclusions on expenses such as consumables, administrative fees, registration fees etc.
- Maternity expenses like pre/post-natal costs, hospitalization expenses incurred during childbirth, etc.
- Outpatient expenses, where you meet the doctor and a procedure is done in the outpatient/ OPD (without admission) category.
- Admissions without an active treatment - this includes situations where you are admitted to a hospital only for observation or monitoring purposes.
2️⃣ Additional permanent exclusions
An insurer may sometimes find it difficult to provide cover if you have a history of certain diseases. In such a case, the insurer will offer you health insurance cover only if you agree to permanently exclude those diseases.
For instance, you were diagnosed with an early-stage cancer when you were a kid which is now cured. The insurer learns about this from your medical history. Now, the insurer might still not cover cancer (even though it is cured) and will provide you cover only if you agree to have cancer as an exclusion to your policy.
When you take a health insurance policy, you’ll not be able to make a claim for all the diseases/ conditions from day one.
There will be some diseases that won’t be covered for a short period after the policy is issued. This period is called the ‘waiting period’. Once the waiting period is completed, these temporary exclusions are removed and you’ll be allowed to claim for these conditions as well.
Temporary exclusions are put in a health insurance policy largely so that the policy remains viable and no frauds happen. Here’s a list of some common temporary exclusions that might be imposed right after your policy is issued -
- Initial waiting period: All medical conditions except accidents are temporarily excluded for the first 30 days after the policy is issued. Meaning, you won’t be able to make a claim for any hospitalization for 30 days - except in case of accidents.
- Pre-existing conditions: A pre-existing condition is any medical condition or illness that you have had in the 48 months (4 years) before applying for the policy. There is a standard waiting period of 3-4 years for pre-existing conditions. The policy will not cover any expenses related to your pre-existing condition during this period.
- Other conditions: Every insurer will provide a specific list of illnesses/ medical conditions (apart from your pre-existing diseases) that will have a waiting period of around 2-4 years. This waiting period will be applied regardless of whether or not you have had those diseases in the past. This is based entirely on the insurer and not on your health.
While it is important to understand how much cover your health insurance will provide and for which costs, it is equally important to know what costs won’t be covered. Understanding this at the time of purchase will help you decide whether the plan is right for you, or not - so you’re not taken by surprise at the time of the claim. Plus - you’ll know the amount of healthcare fund you will need to create, in the long-term (for all the conditions that are not covered) - so you can start building this early in life.
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- In health insurance, exclusions are the situations for which your plan will not pay.
- Common exclusions in health insurance are categorized into two - permanent exclusions and temporary exclusions.
- Permanent exclusions are illnesses that your policy will never cover.
- Temporary exclusions are situations that are not covered for a certain period after the policy is issued.
- Buy a policy after considering all permanent and temporary exclusions in your policy - so that you can be better prepared for any payments you’ll have to make out of your own pocket, at the time of the claim.
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