08 Jul, 2021 | Health Insurance

Your Health Insurance Policy Doesn’t Cover That!

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Introduction

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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Permanent Exclusions in Health Insurance

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. 

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Permanent exclusions are of two types -

1️⃣ Standard permanent exclusions

There are certain codes set by IRDAI for various exclusions - which are standard and must be followed by every insurer. In addition to these, these are also exclusions that insurers apply to most health insurance policies - which they mention in their policy wordings. 

Here’s a list of top permanent exclusions you should watch out for - 

  • Investigation and evaluation: Admission to a hospital only for observation or monitoring purposes. 
  • Rest cure, rehabilitation and respite care: Expenses incurred for admission to any facility primarily for bed rest - where no active treatment is carried out.
  • Obesity / weight control: Any treatment or surgery done for weight control or obesity. 
  • Change of gender treatment: Treatment carried out to change the characteristcs of the body to those of the opposite sex.
  • Cosmetic or plastic surgery : Surgery or treatment conducted to change your appearance or body features.
  • Profession in hazardous or adventure sport: Any treatment expenses incurred while you’re working as a professional in adventure activities like river rafting, mountaineering, scuba diving, horse racing, etc. 
  • Breach of law: Expenses incurred towards the treatment of a person who has committed or has attempted to commit a breach of law with criminal intent.
  • Excluded providers: Getting treatment from a medical practitioner or in a hospital that is excluded by the insurance company. 
  • Unproven treatments: Surgeries, medical procedures, or treatments undergone that are not proven to be effective.
  • Drugs and narcotics: Treatment carried out for alcoholism, drug or substance abuse, or any addictive condition.
  • Maternity expenses: Pre/post-natal costs, hospitalisation expenses incurred during childbirth, etc. 
  • Outpatient expenses: Expenses incurred when you meet the doctor and a procedure is done in the outpatient/ OPD (without admission) category.
  • General exclusions: Expenses such as consumables, administrative fees, registration fees, etc. 

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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. 

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Temporary Exclusions in Health Insurance

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 hospitalisation for 30 days - except in case of accidents. 
  • Pre-existing diseases waiting period: 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. 
  • Specified disease/ procedure waiting period: 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. 

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What Happens to the Waiting Period if you increase your policy sum insured?

In case you decide to increase your existing sum insured at the time of renewing your policy, the insurance company will impose a fresh waiting period for the increased sum insured. 

Let’s understand this better with the help of an example.

Sum InsuredWaiting Period Start DateWaiting Period End Date
Original sum insured: INR 10 LakhsJanuary 2020January 2022
Increased sum insured: INR 5 LakhsJanuary 2021January 2023

Say you purchased a health insurance plan for INR 10 Lakh in January 2020, and the insurer applied a 2 year waiting period for diabetes. This means you cannot claim for diabetes until January 2022. 

In January 2021, you decide to increase your sum insured by INR 5 Lakh. Now, a 2-year waiting period will be applicable for diabetes for the increased amount. Meaning, you cannot claim for diabetes until January 2023 for this increased amount, i.e., INR 5 Lakh.

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Can you transfer the waiting period while porting your policy?

Portability is the process through which you can transfer your current health insurance policy to another insurance company. While porting your health plan, some insurers allow transferring the waiting period credit (for both pre-existing and other diseases) if you’re covered continuously under your health insurance policy without any break. This is as per the portability norms of the extant IRDAI (Health Insurance) Regulations.

In Conclusion!

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. 

Still got a question about health insurance exclusions? Our community is here to help. :-)

Post your query on the Beshak Forum - to get a response in less than 6-8 hours!

Key takeaways
  1. In health insurance, exclusions are the situations for which your plan will not pay. 
  2. Common exclusions in health insurance are categorized into two - permanent exclusions and temporary exclusions.
  3. Permanent exclusions are illnesses that your policy will never cover.
  4. Temporary exclusions are situations that are not covered for a certain period after the policy is issued. 
  5. 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.
Team Beshak
Written by,
Team Beshak, We breathe insurance :)

We are a group of young members of the Beshak community. We come together to brainstorm, write relevant and useful content for people (just like us) who want to figure insurance on their own. If you too want to share inputs/write for us - send us a "hey" to info@beshak.org

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