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10 Most Important Health Insurance Exclusions

Team AckoJun 7, 2024

There is a famous saying that goes, ‘Health is Wealth.’ And when you are healthy, you can go ahead and face the world. However, in the fast-paced world we are living in, health and wealth are both things that need to go hand in hand. Without a strong financial backup, you may forget the idea of good health.

Speaking of which, you are at the right place if you are looking for health insurance. Health insurance in India is known to cater to your financial needs in dire situations where you need funds. It goes without saying that it is less stressful for you when you have health insurance by your side.

Technically, a health insurance policy is a contract that specifies the terms and conditions of the insurance company along with what is covered under the policy. This document also enlists the situations that will not be covered under the policy. This means the policyholder cannot raise a claim for a situation that is listed under exclusions. In this article, we will take a look at 10 such conditions that you need to be aware of.

Important

Contents

What is health insurance?
10 Most Important Health Insurance Exclusions
Few Additional Exclusions
Frequently Asked Questions:

What is health insurance?

Health insurance is something that has, over time, become the most important need in our lives. Basically, it covers the surgical and medical expenses of a person who is insured. It reimburses the cost incurred because of the illness and/or injury and goes ahead and pays the care provider of the insured individual directly.

10 Most Important Health Insurance Exclusions

Such procedures require a good amount of money these days. However, maternity benefit may not be covered under a normal health policy. To get this coverage, you may need to get in touch with an insurer and inquire about the availability of a specific policy or an Add-on.

#2 Cosmetic surgery

A cosmetic procedure done to enhance certain body parts is mostly not covered under medical insurance. Thus, if you wish to undergo any such procedure you may have to arrange the required funds by yourself. It is important to note that many insurance companies might cover cosmetic surgeries in case of a major accident causing disfigurement.

#3 Teeth, Ears, and Eyes

Any medical procedures related to dental issues, hearing, or vision may not be covered under medical insurance. This is simply because such surgeries do not require inpatient hospitalization.

#4 Pre-Existing Diseases

Most of the health insurance companies do not cover pre-existing diseases. If they do, there may be a waiting period applicable for availing the coverage. It is important to check the coverage while buying the medical insurance policy.

#5 Therapies and Alternative Treatments

After an accident, a person may have to undergo follow-up treatments such as physiotherapy. Some people may undergo alternative treatments like Ayurveda, etc. These procedures may not be covered by your insurer as only allopathic treatments may be included.

#6 Self Inflicted injuries

Suicide attempts i.e. intentional harm to oneself is not covered by many health insurance companies.

#7 Joint replacement

One of the most common surgeries people undergo is joint replacement surgery. The need may arise due to factors like old age or some diseases. However, the expense arising from these surgeries may not be covered by your insurer.

#8 Waiting Clause

As mentioned earlier, some conditions have a waiting clause applicable to them, these could be maternity benefits or pre-existing diseases. A waiting period may range from 2 to 4 years depending upon the insurer. You need to read the policy document to understand this clause specified by your health insurance company.

#9 Specific Expenses

Your health insurance in India may list some limits on expenses that will be borne by your insurer. These could include a sub-limit on room rent or doctors’ fees. Ancillary services like ambulance, lab tests, etc. may also not be covered.

#10 Permanent exclusions

Some situations are permanently excluded from your health insurance policy. These are: HIV, war, nuclear activities, congenital diseases etc.

Few Additional Exclusions

Here are some of the additional exclusions of health insurance:

Ailments that are lifestyle-related

Hospitalisation that has happened due to excessive intake of alcohol or smoking is not covered by health insurance. Additionally, the health policies for individuals with bad habits come with high premiums.

Diagnostic expenses

There are many routine tests like the blood test and diabetes tests. These tests are generally not covered by healthcare insurance. However, if, due to these tests, the individual needs to be hospitalised, then the test will be covered.

The Bottom Line

Health insurance provides a financial backup in case of an emergency. However, it is important to understand that an insurer may have certain limitations on the policy. It is always a good idea to familiarise yourself with exclusions before purchasing the health policy.

Frequently Asked Questions:

Here are some Frequently Asked Questions related to the above topic

Why do I need health insurance?

Helping you protect yourself from high medical costs in case of unexpected happenings is the ultimate protection.

What does a typical health insurance cover?

From preventive care to emergency services, there is a range of health insurance coverage, but it depends on each of them.

How do you choose the right health insurance?

When you are trying to select a health insurance plan, there are a few factors you need to consider, such as monthly premiums, coverage limits, deductible co-payments, etc.

What is deductible?

A deductible is the sum you must pay from your pocket for covered services before the insurance starts to pay.

Can I get health insurance if I already have a condition?

It depends on one healthcare system to another. Learn more about the insurance of your choice to find out more.

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Disclaimer: *Except for exclusions like maternity benefits, undisclosed diseases, etc. Please check policy wordings for more details.

**The content on this page is generic and shared only for informational and explanatory purposes. It is based on industry experience and several secondary sources on the internet; and is subject to changes. Please go through the applicable policy wordings for updated ACKO-centric content and before making any insurance-related decisions.