A health insurance policy is designed to help policyholders account for the cost of treatment, hospitalisation, and related medical expenses without denting their savings. However, not all claims raised under a health insurance plan are guaranteed to get settled. This typically happens when a given situation is not covered by the health insurance plan or is laid down as an exclusion of the policy. 

In order to avoid confusion during a medical emergency and to ensure claim settlement individuals must check the exclusions of the health insurance policy beforehand. 

That said, let us give you a head start about health insurance exclusions and why one should know about them in detail below. 

What are the Health Insurance Exclusions? 

Essentially, exclusions are described as legal conditions under which an insurance company is not liable to settle a policyholder’s claim. Notably, both standardized and non-standard insurance policies come with exclusions that may assume many forms. For instance, sometimes claims arise from how an insurance policy defines accidents, lifestyle diseases, or critical illnesses. 

Note that insurance companies can exclude certain events for their approved set of claim events. For instance, death by suicide, accidents owing to acts of God, or self-injury are widely deemed as exclusions. 

Most of the time, exclusions can impact the extent of insurance coverage. Take, for example, the cost of treating existing diseases in an insurance policy, outpatient charges, etc. are not accounted for. 

Why is it important to Check Health Insurance Exclusions in Advance? 

All health insurance exclusions are stated clearly in the policy document. Reading the fine print clearly will help individuals understand what to expect from an insurance policy, especially in case of an emergency. It will also help determine whether a particular insurance policy is adequate to account for your specific needs or whether it will fail to provide basic financial coverage to the insured. 

By comparing leading health insurance policies, individuals can gain a better idea about the standard exclusions across all insurance policies which will aid in picking a suitable plan with maximum coverage.  This will in turn allow users to prepare better for those standard exclusions that are common to most leading insurance policies. 

Common Health Insurance Exclusions 

Here’s a list of a few common exclusions under Health Insurance plans –

1. Pre-Existing Illnesses

The medical condition that the policyholder is suffering from at the time of buying a health insurance policy is termed a pre-existing illness. Note that some pre-existing illnesses such as diabetes, hypertension, and thyroid might be covered under certain health insurance policies. However, the same is often entertained after the expiry of a specified waiting period. 

The list of such illnesses and waiting periods tend to vary among insurance providers. 

any medical condition that the insured is suffering from at the time of taking the policy is known as Pre- Existing Disease. It is not covered under health insurance. However, some of these might be covered after a certain waiting period. A few examples of these Pre-Existing Diseases are Diabetes, thyroid, Hypertension, etc.

2. Specific Illnesses and Medical Procedures 

Illnesses such as cataracts, mental illness, and hernia, may not be covered by all health insurance policies. Similarly, procedures such as bariatric surgery and joint replacement are often not included in insurance coverage. 

However, if specific illnesses or procedures do make it to the coverage list then they would accompany a specific waiting period. Only when the waiting period for such illnesses and procedures is completed, individuals can make intimate claims under the insurance policy. 

3. Pregnancy and Childbirth

One should note that many standard health insurance policies do not cover an individual’s pregnancy and childbirth. Maternity expenses are usually offered as an add-on with regular health insurance plans.

However, one should note that insurance that covers maternity expenses usually comes with 1-2 years of a waiting period. Picking an addon with the least waiting period is often advised. Similarly, abortions and infertility treatments are not covered under health insurance policies. 

4. Diagnostic and OPD Treatment Expenses

Usually, health insurance plans do not cover the cost of diagnostics and even OPD treatments. However, some insurance plans may account for both OPD expenses and diagnostics charges mostly as part of an existing plan like an add-on perk. This will help individuals to account for the charges without dipping into their savings or pension plan.

5. Adventure Sports-related Treatment

Expenses incurred to treat any injury or discomfort caused due to participation in any adventure sports. In other words, adventure sports such as rock climbing, para jumping, motor racing, skydiving, mountaineering, scuba diving, etc., come under exclusions when practiced professionally. This means individuals who participate in any recreational adventure sport or activities under the supervision of a trained professional then they would be covered under the insurance policy. 

6. Permanent Exclusions

Health insurance plans also lay down certain permanent exclusions. For instance, self-inflicted injuries, congenital diseases, war-inflicted injuries, and injuries from suicide attempts are all excluded from insurance coverage. 

7. Substance Abuse and Addictions 

Notably, expenses arising due to substance abuse and addictions are excluded in the following cases:

All expenses incurred during the treatment of an illness or accidental injury caused due to – 

• Misuse/abuse of alcohol, nicotine, drugs, or opioids.
• Deaddiction treatment charges
• Any claims made toward oral cancer, respiratory system, oropharynx, etc. are not entertained by the insurance policy, especially when the insured is a chronic tobacco user. 

8. Cosmetic Treatment

Cosmetic treatments like plastic surgery do not get covered by a health insurance plan. Since cosmetic treatments are considered dispensable to maintain a person’s life, they are not deemed essential and hence they are not covered. However, when cosmetic surgery is medically essential and involves the insured getting hospitalised, say in case of an accident, the expenses arising out of the process are covered in the policy. 

Keep these exclusions in mind when looking for an insurance policy to pick the one with the least limitations. Subsequently, find out the claim settlement ratio of the insurance company and the claim process to ensure the policy provider will approve the claim in times of need and will not require a cumbersome approval process. This will help pick the best health insurance policy and allow the insured to benefit from its perks without any issues.