Thursday, 21 January 2016

Medical Conditions That Your Health Insurance Policy Doesn't Cover


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The term exclusion is used in health insurance when an event of medical emergency/need is excluded from an existing health insurance policy. There are many types of medical conditions that are not covered by your health insurance policy; therefore, it would be good for you to read carefully what does your policy cover and doesn’t cover? Usually, after buying a health insurance policy, insured receives a copy of terms and conditions along with a list of doctors in his network through email or post.  It is immensely important to read all terms and conditions related to a health insurance policy to minimize the chances of claim rejection. It is remarkable that insurance companies strictly follow their terms and conditions stated in specific policy; which means customer’s claim will be rejected if claimed medical emergency is not stated in their terms and conditions page. Therefore, it is advisable that after buying a health insurance policy promptly read all terms and conditions of your policy to understand what does your policy cover and doesn’t cover? You may request your insurer to send a copy of terms and conditions before buying a health insurance.
In this post, we are highlighting major exclusions which are almost available in all health insurance policies; however, complete detail of exclusions can be obtained from your insurer’s policy documents. Often, customers assume that their health insurance policies cover all the medical expenses incurred in a hospital, but in reality, your insurer covers only certain types of medical expenses. Here are some major exclusions in a health insurance policy;
Health Insurance Exclusions

Disclaimer: The information and benefits provided herein are for informational purpose only and you may find some variations in exclusions. Please do not take it as a legal advice. 

30 Days Initial Waiting Period


Often, insurance companies do not provide health cover for medical expenses for first 30 days of the policy; unless the cover needed for injury caused by an accident. As per 30 days initial waiting period, your insurer is not liable to pay you any claim for medical expenses in first 30 days of the policy. This rule does not applicable in subsequent years. The waiting period does not reapply when the policy is renewed; except policy is renewed after a break. Incase policy is renewed after a break then waiting period will reapply on revived policy as like first year.

Pre-existing Medical Conditions


No insurance company covers pre-existing medical conditions for first 3-5 years. Pre-existing medical conditions are the diseases or illnesses that the insured had before applying for the health insurance. That’s why, insurance company conducts a medical exam of insured to find out whether he/she is suffering from any chronic disease or not.  

Waiting Period For Certain Illnesses


Like 30 days initial waiting period, insurance companies do not provide coverage for certain type of illnesses. Listed illnesses will be covered from the commencement of the 2nd-3rd   policy year if the insured or policy holder continuously paying the premiums. It is also noticeable that if policy is revived after expiration of grace period then all types of exclusions and waiting periods will be applied afresh. Here are some illnesses that insurance companies put into waiting period;

  • Joint replacement; unless due to accident
  • Piles or Gastric and Duodenal Ulcers
  • Stones in biliary and urinary systems
  • All types of Hernia and tumors
  • Gout/Arthritis/ Rheumatism/Osteoarthritis/Disc Prolapse
  • Cataract
  • Dilation and Curettage
  • Varicose veins
  • Diabetes
  • Laser surgery
  • Benign Prostatic Hypertrophy
  • Surgery on tonsils/adenoids

Permanent Exclusions


Apart from all exclusions, there are some permanent exclusions in health insurance policies; which means insurance companies will never pay for these types of medical conditions. Where in other exclusions after a certain time period, insured becomes eligible for medical expenses and services; in permanent exclusions nothing exists like that. Almost all companies have same exclusions; nevertheless, reading your own policy documents can guide you better. Here is a list of permanent exclusions;

  • Any type of life support system which cannot restore previous state of health.
  • Treatment for any illness or injury due to war, nuclear war, riot, chemical contamination, acts of terrorism etc.
  • If insured person deliberately puts himself/herself in danger situations.
  • If insured is staying in hospital without requiring any type of treatment.
  • Cosmetic Surgery: If insured person wants a cosmetic surgery to improve his/her appearance.
  • Dental/Oral Treatment which does not require to be hospitalized.
  • No claim for eye related issues unless insured needs to be hospitalized due to accident.
  • If insured person gets sick due to taking treatment from wellness clinics, natural cares or in other words place that is not a hospital.
  • HIV and AIDS: Treatment required for Human Immunodeficiency Virus or Acquired Immuno Deficiency Syndrome.
  • If insured suffering from a genetic disorder or problem.
  • Illness due to drug overdose.
  • Getting extra treatment from private bodies on pre and post-hospitalization.
  • If medical officer or doctor gives fitness certificate that insured is capable of pursuing his/her life as before illness.
  • No payouts for treatments from streams like; ayurvedic, homeopathic etc.
  • Treatment of obesity.
  • Self-inflicted Injuries.
  • Sexual Problems and gender related problems.
  • Speech and Sleep Disorders.
  • If insured person is getting treatment to reduce the symptoms of ageing.
Above are the major permanent exclusions; you may find some more permanent exclusions in your medical care policy.
NOTE: You may buy riders to cover a medical condition that is not covered by your policy.     
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