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Understand What Is And Isn't Covered By A Health Insurance Policy

Updated On May 17, 2022

It is suggested that you do your research and planning before selecting a health plan. It will help you choose a health insurance policy that has minimal exclusions and offers maximum coverage. Furthermore, medical insurance plans would generally exclude certain illnesses from the first year of coverage and cover it after the waiting period is over.

There are certain standard sets of exclusions like the cost of contact lenses, spectacles, and hearing aids that are not covered. Also, dental surgery/ treatment ( unless requiring hospitalization), congenital external defects, convalescence, venereal disease, general debility, use of intoxicating drugs/alcohol, Self-inflicted injuries, AIDS, diagnosis expenses, infertility treatment, and Naturopathy treatment make a list of exclusions under health insurance plans in India.

Understand What Is And Isn't Covered By A Health Insurance Policy

What Is Covered Under A Health Insurance Policy?

  • Accident-related injuries

Typically, all Mediclaim policies cover the treatment cost for accident-related injuries. Depending on the policy terms, you can get full coverage for the expenses, including inpatient hospitalisation, post-hospitalisation care, diagnostic tests, etc. Additionally, you can avail the cashless claim facilities for such costs provided you avail treatment at any of the insurer’s network hospitals.

  • Cataract surgery

This is one of the common diseases covered under health insurance. A cataract is an eye-related ailment that affects the vision, and it mainly occurs among senior citizens. Typically, the treatment of cataract requires surgery. Except for the group health insurance policies, most healthcare plans cover cataract surgery. However, there may be a waiting period before the cover applies.

  • Cancer

Cancer is one of the most dreaded diseases. Depending on the seriousness of the patients’ condition, and the type of cancer they are diagnosed with, the treatment cost for cancer can run into several lakhs. Cancer patients often require special care and prolonged hospitalisation and post-hospitalisation treatment like chemotherapy, radiation therapy, etc.

Typically, all health insurance plans cover cancer treatment, but they may be subject to terms and conditions. For example, if the cancer is detected in the late stages, the policy may have sub-limits on the hospitalisation expenses, or there may be a waiting period before it comes under the policy inclusions’ gamut. Be aware of the policy terms while filing the claim.

  • COVID-19

With the rising number of COVID-19 cases in India and the increasing risk of the disease, the Insurance Regulatory and Development Authority of India has mandated all the insurance companies in India to cover COVID-19 under the current policy. COVID-19 is a deadly virus, and its treatment requires specialised care. With a robust health insurance policy at hand, you can breathe a sigh of relief knowing that the insurer will take care of the treatment cost.

  • Dengue

This is one of the common diseases covered under health insurance. Although not a serious condition, sometimes, if left untreated, it can lead to fatal consequences. Most insurance policies cover Dengue reimburse all medical costs incurred on the treatment, irrespective of whether you need hospitalisation or not; the policy also covers daycare expenses.

  • Diabetes

Diabetes is a common health problem among both men and women. Depending on the personal health condition, the disease can cause various complications, and often the patients may need to be hospitalised. Depending on your policy terms, you can get coverage against all expenses, including the blood tests, insulin shots, doctor consultation fees, medicines, etc.

What Isn't Covered Under A Health Insurance?

  • Cosmetic Surgeries

Cosmetic surgeries like Botox, Liposuction, implants and similar surgeries are excluded from a health insurance policy. You can check with your insurer if you plan to undergo any such surgery during the policy term. Unless it is a part of the treatment, insurance companies do not compensate for such medical procedures.

  • Pre-existing Illnesses

Pre-existing diseases and related waiting periods vary from one insurance company to another. Some insurance providers may provide cover for diabetes, blood pressure, heart patients, etc. Most of the health plans would include such expenses only after the waiting period is completed, which can range from 12 months to 48 months. However new health plans are being launched that provide PED cover from Day 1.

  • Infertility/Pregnancy related complications

Hospitalization expenses related to infertility/pregnancy complications like abortions are excluded from health insurance coverage. In some maternity health plans, these expenses can be covered, but in basic health plans, these expenses are not covered. You can check your policy wordings if you are specifically looking for coverage for pregnancy-related expenses. You can also check out women specific health plans to cover such expenses.

  • Health Supplements

Under your health insurance policy, the insurer does not provide financial cover for health tonics and supplements. If these are recommended by the treating doctor then the expenses might be claimable. But if you are taking it without any prescription then it shall not be a part of policy coverage.  For details, you can refer to the policy wordings.

  • Diseases related to Overconsumption of Alcohol

If any illness is tracked to overconsumption of alcohol like liver damage, and other problems, then the insurance company holds the right to reject your health insurance claim.

  • Expenses incurred on Alternative Therapies

Any expenses that you incur on alternative therapies like naturopathy, acupressure, naturopathy, acupuncture, reflexology, and similar expenses are excluded from health insurance coverage.

  • Diagnostics Charges

Any expense incurred on diagnostic or pathological services like scans, blood tests, and other body tests performed at a nursing home or hospital are excluded unless the policy covers them specifically or it is required as a part of the treatment. 

Conclusion

So, to avoid going through such a negative experience and manage your finances better, read your policy wordings till the end to have better clarity on both the inclusions and. the diseases that are excluded from health insurance scope of coverage.

Also read- Is Orthopaedic Surgery Covered Under Health Insurance?

Ways To Stay Healthy And Fit

Disclaimer

This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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