Health Insurance Exclusions: a health insurance claim would be admitted only if all the 3 conditions are fulfilled, such as doctor’s advice of hospitalisation, standard protocol for treatment and an active line of treatment has been administered.
A large number of covid related claims were made following the rise of Covid cases during the second wave. As on May 5, 2021, about 47.8K covid claims were repudiated while about 187.8K claims were still under review, according to the data published by the General Insurance Council. These health insurance claims were primarily rejected for lack of proper documentation, waiting period and exclusions.
Dhirendra Mahyavanshi, Co-Founder, Turtlemint (An InsurTech Company) says that after the IRDAI’s guidelines about proper scrutiny of covid claims before rejection, insurers have become way more inclusive in recent times.
“New and improved features like coverage for mental disorders, robotic and advanced surgeries, the inclusion of telemedicine, etc. have expanded the scope of health insurance plans and made them popular. However, the waiting periods and exclusions still form an important part of any health plan. Even with standardized exclusion norms, there is a lot that an insured needs to be aware of before purchasing the plan,” Mahyavanshi told FE Online while explaining the most common health insurance exclusions every insured person should know. Take a look:
Pre-existing illness exclusion during the waiting period
The Turtlemint Co-Founder said that if you are suffering from any medical condition, like diabetes, hypertension and the like, such condition would be called a pre-existing condition. “Complications arising out of such pre-existing conditions would not be covered during a waiting period specified under the policy. The period ranges from 12 months to 48 months. Once the period is over, you can avail of coverage for your pre-existing conditions.”
Standard waiting period
Besides the waiting period for pre-existing conditions, there are other waiting periods too during which specified coverage is not available. These periods include the following:
Initial waiting period: Mahyavanshi said this is also called a cooling-off period from the date of buying the policy. Illnesses incurred during this period are not covered. However, accidental injuries would be covered during this period which usually lasts for 30 days.
Specific waiting period: Illnesses and treatments like hernia, fistula, tonsillectomy, cataract, joint replacement surgeries, etc. are not covered in the first one or two years of the policy.
Maternity waiting period: If the plan allows maternity coverage, there would be a waiting period within which the coverage would not be available. The period ranges from 9 months to 48 months.
Cosmetic treatments: Cosmetic surgeries are not medically necessary, except when they become important for treating an accidental injury. Such, non-necessary cosmetic treatments are, therefore, excluded from the scope of coverage. Moreover, even circumcision and gender-change treatments are excluded from coverage.
Unscientific treatments: If you avail of unproven, experimental or unscientific treatments, the cost of such treatments would not be covered under your health insurance plan. Clinical trials are the most common examples of this instance and if you avail treatments under such trials, where the line of treatment is not commonly accepted by medical professionals, you would have to bear the medical costs.
Self-harm: Injuries or illnesses suffered due to self-harm attempted suicide, deliberate actions of the insured or self-inflicted injuries are not covered under the policy. This is because health plans are meant to cover uncertain medical emergencies over which you have no control. If you do control the occurrence of medical contingencies, such contingencies would be excluded from coverage.
Participation in hazardous activities, criminal acts and injuries suffered due to alcohol or drug abuse are also excluded from coverage.
War and allied perils: Medical injuries suffered when the country is at war, or if there is a mutiny, rebellion or civil unrest, would not be covered. Illnesses and injuries due to radiation or chemical ionisation are also not covered.
Investigation and evaluation costs: The medical costs incurred on investigative tests are covered provided they are incurred in relation to the treatment for which you have been hospitalised. However, if the tests are not related to the treatment for which you are making a claim, their costs would not be covered. Moreover, if you are hospitalised only for the purpose of undergoing investigative or evaluative tests, the cost of such hospitalisation and such tests would not be covered.
Dietary supplements: The costs incurred on buying vitamins, minerals and other dietary supplements are not covered under the policy.
Cost of consumables and non-payable items: Consumables are one-time use objects which are used in the course of treatments. For example, cotton, bandages, syringes, face masks, sanitisers, etc. constitute consumables.
Such consumables are not covered under health insurance plans and their costs would be your out of pocket expenses. Similarly, the regulator has specified a list of non-payable items under health insurance. The cost of items contained in such a list is also not covered.
“However, modern-day health plans are allowing add-ons that allow you to seek coverage for these non-payable items and consumables.
3 conditions to get health insurance claim
According to Mahyavanshi, a health insurance claim would be admitted only if all the 3 conditions are fulfilled, such as doctor’s advice of hospitalisation, standard protocol for treatment and an active line of treatment has been administered.
“If all these 3 clauses are fulfilled and there are no exclusion or documentation concerns, there are no reasons for claim to be repudiated. However, when buying a health insurance plan, read the fine print. Go through the list of coverage exclusions to know exactly what is covered by the plan and what isn’t,” he suggested.