By Manju Dhake
Have you ever faced a situation where you have a health insurance policy and your claim is not being processed? There may be instances where the claim is denied due to the standard exclusions or waiting periods specified in the policy. It is therefore preferable to check “what is not covered by the policy” rather than “what is covered by the policy.”
Let us understand some important points on standard exclusions in the health insurance policy:
Initial waiting period (30 days)
- There is an initial waiting period of 30 days in the policy. This means, whenever you have taken a policy, you have to wait for 1 month to make a claim.
- 30-day waiting period (Excl03) are the expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered
Specified diseases (2 years)
- There are certain specified diseases that are mentioned in the policy document and are covered after 2 years.
- These are the expenses (Excl02) related to the treatment of the listed conditions, surgeries/treatments which shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy.
- This exclusion shall not be applicable for claims arising due to an accident.
- The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
- If the Insured is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then the waiting period for the same would be reduced to the extent of prior coverage.
Some of the listed conditions mentioned in a health insurance policy are:
- Any type of gastrointestinal ulcer
- Any type of fistula
- Macular Degeneration
- Benign prostatic hypertrophy
- Hernia of all types
- All types of sinuses
- Fissure in ano
- Haemorrhoids, piles
- Dysfunctional uterine bleeding
- Uterine Prolapse 1
- Stones in the urinary and biliary systems
- Surgery on ears/tonsils/ adenoids/ paranasal sinuses
- Surgery on all internal or external tumours/cysts/ nodules/polyps of any kind including breast lumps.
- Mental Illness
- Diseases of the gall bladder including cholecystitis
- All forms of Cirrhosis
- Gout and rheumatism
- Surgery for varicose veins and varicose ulcers
- Chronic Kidney Disease
- Alzheimer’s Disease
Pre-existing Diseases – (4 years)
Many of us know, the existing ailment or disease is covered after 4 years in the policy. However, let us understand the same in more detail with the help of the wording in the standard exclusion clause.
Pre-existing disease (Excl01) means any condition, ailment or injury or disease;
- That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement Or
- For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.
In simple terms, before taking a health insurance policy, if you are under medication or have a certain ailment which is diagnosed 48 months prior to taking the policy, this is termed as a “Pre-existing disease” and the claims related to the same shall be covered after 4 years.
These are the standard exclusions so that no one can make a profit out of insurance, which defeats its purpose. Few people enter into the product only when they are triggered with any ailment and assume that they can claim in the policy immediately and cover the financial loss.
One must hence, understand that “Insurance is to indemnify the uncertain loss covered in the policy and runs on the principle of “Uberrima Fides” (Utmost Good Faith) and “Principle of Indemnity”. It is a tool to save you from uncalled emergencies and should not be looked at for Profit making.
Hope the above exclusions in the form of a waiting period shall help you understand the policy in more detail and the intent behind such standard rules.
(Please Note: Exclusion clause policy wordings and list of conditions are taken from standard policy wordings from the available public sources)
(The author is Vice-President, Insurance at 1 Finance, a personal finance advisory platform. Views expressed are personal)