Things That are not covered under Medical Insurance


Things That are not covered under Medical Insurance

Diseases That Are Not Covered Under Health Insurance

After spending 3 years of togetherness, Nirja and Rahul, a happily married couple, have decided to enter into parenthood. Soon, Nirja was diagnosed with a severe infertility problem, and her gynecologist suggested her surgery. Counting on her health insurance policy, she started the treatment from the top infertility centre to avail of the best possible healthcare. However, she was disappointed when she came to know that her insurance company rejected her claim. Left with no clue, Rahul and Nirja met the hospitalization expenses from their pocket. This incident derailed their lives and finances. Later, she came to know that infertility treatment comes under the insurance company’s exclusion, that’s why she was not entitled to get the reimbursement. So, to avoid such scenarios that can impact your finances, read this article till the end to have clarity on what types of diseases are not covered under health insurance. But, before that, let’s understand what exclusions in health insurance claims are?

Health Insurance Exclusions

Health insurance exclusions are situations and cases that are not covered under the policy according to the guidelines given by IRDAI. The insurance provider has the full right to reject the claims related to the diseases or treatment that comes under exclusions.

It is better to do your research and planning before opting for a health cover. That way, you can choose a policy that offers maximum coverage with minimal exclusions.

Read the diseases not covered under a health insurance plan:

  • Pre-existing Diseases: Any diagnosis of diseases / undergoing of surgery/occurrence of an event, for which the signs or symptoms occur within 30 days of policy period start date.
  • Self-Inflicted Injury: Any treatment expense arising due to self-inflicted injury, such as suicide and attempted suicide.
  • Consumption of Alcohol: Any expense arising out of or attributable to use/misuse/abuse of alcohol/drug
  • Pregnancy and other related conditions: Any medical treatment costs related to pregnancy, childbirth, miscarriage, abortion, and its consequences are not covered.
  • Infertility Treatment: Medical tests and treatment relating to infertility and in vitro fertilization cannot be claimed.
  • Permanent Exclusions: War, riot, strike, and nuclear weapons induced hospitalization are considered permanent exclusions.
  • Cosmetic Surgery: Plastic surgery, cosmetic treatment, and implant are also not covered under a medical insurance policy.

The IRDAI issued guidelines in September 2019 under the Standardization of Exclusions in Health Insurance Contracts for standardizing of wordings for health insurance exclusions that will help many policyholders.

Check: Mediclaim Policy Premium Calculator

Need for Health Insurance Exclusions

Exclusions include the various cases where a policyholder is not eligible to get a claim under a health policy. Such expenses excluded from the policy coverage will have to be borne by the policyholder. Health insurance exclusions are mentioned as per IRDAI guidelines. 

Exclusions narrow the scope of insurance coverage. Read below the need for health insurance exclusions:

  • It carves the coverage for risks that the insurer not willing to reimburse.
  • Some risks are uninsurable. They can affect several policyholders at one go — for example, war and natural calamity.
  • Some treatment and hospital expenses are manageable, so no need to cover them under an insurance claim.

Sum Up!

Having a Health Insurance Policy provides financial support during a medical emergency by covering your healthcare expenses. However, insurance providers have a limited window. It’s difficult for them to cover all sorts of diseases under one cover. Therefore, exclusions give a sense of responsibility to a policyholder not to file a claim against petty medical expenses. If you plan to opt for health insurance, prefer the plans offered by Care Health Insurance that has minimal exclusions with maximum coverage. You should go through the exclusions list and see what diseases are not covered under health insurance to make the most out of it without facing any hassle.

Disclaimer: Please read the brochure and prospectus to know more about our health insurance plans cover as conditions may vary.

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