Exclusions under a health insurance policy

Exclusions are the features that are not usually covered under health insurance policies. Exclusions are standardized across the country by the regulatory body IRDAI. It’s important to understand the exclusions to ensure a better understanding of what all is covered under your health insurance policy. According to the circular, there are two parts of the exclusions mandate : 

Part 1- The points that cannot be excluded by health insurance providers

Part 2- Permanent Exclusions 

Part 1: Following points cannot be excluded by the health insurance providers:
  1. Injury or illness associated with hazardous activities. However, it is important to note that only treatment necessitated due to professional participation in adventure or hazardous sports is permitted as an exclusion.
  2. Any mental issue arising from the usage of drugs, stimulants, or depressants which have been prescribed by a medical practitioner
  3. Artificial Life Maintenance: The policy will cover a person’s medical bills till the doctor treating the patient declares the patient to be in a vegetative state.
  4. Treatment of mental illness, stress or psychological disorders, and neurodegenerative disorders.
  5. Puberty and Menopause related disorders: Treatment for any symptoms, Illness, complications arising due to physiological conditions associated with Puberty, Menopause such as menopausal bleeding or flushing.
  6.  Age-Related Macular Degeneration (ARMD) usually results in vision loss of elderly patients.
  7.  Behavioral and Neurodevelopmental Disorders include

                 i.    Disorders of adult personality 

                ii.    Disorders of speech and language which includes stammering or dyslexia

  1.  Expenses related to any admission primarily for enteral feedings that are nutrition taken through the mouth or a tube that goes directly to the stomach or small intestine.
  2.  Internal congenital diseases, genetic diseases, or disorders.
  3. If a specified cause for the medical condition is not known.
  4.  Failure to seek or follow medical advice or failure to follow treatment.
  5. Insurance providers have to cover the diseases that you get after taking the policy other than the points mentioned below.
  • Diseases that have been declared under pre-existing conditions like hypertension, diabetes, heart diseases, lung issues, PCOD/PCOS  by the policyholder will not be covered if the waiting period has not elapsed
  • Specified disease/procedure, if the waiting period has not elapsed. Specific diseases are exactly as the name suggests, a list of specific diseases like diabetes, osteoporosis, cataract, or cysts which are covered after a certain period of time under your health insurance policy. You can refer to the policy document for the exact list of diseases that come under the specific waiting period.
  • Any claim that comes in before completing 30 days of getting the policy
  • Expenses related to primary diagnostics of the conditions that do not require hospitalization.
  • Expenses related to the insured person on enforced bed rest and not for receiving treatment.
  • Any obesity/weight control treatments that have not been prescribed by a doctor.
  • Gender-change treatments.
  • Cosmetic or plastic surgery unless medically required.
  • Treatment required due to injuries that occur because of participation as a professional in hazardous activities like adventure sports or high-risk jobs.
  • Any treatment arising from the insured person attempting unlawful activities.
  • Any medical provider specifically excluded by the insurance company.
  • Treatment for alcoholism, drug or substance abuse, or any addictive condition and consequences.
  • Treatments received in establishments where admission is solely given for domestic reasons eg, spa, nature cure clinics, etc.
  • Dietary supplements or substances that can be purchased without prescription unless prescribed by a doctor and covered under hospitalization claim or daycare procedures. Day Care procedures are the ones that require less than 24 hours of hospitalization.
  • Expenses related to the correction of eyesight due to the refractive error less than 7.5 dioptres.
  • Any expenses related to unproven treatments as they do not have sufficient medical documentation that supports their effectiveness.
  • Maternity and related conditions.
  • Expenses related to birth control, sterility & infertility
Part 2: Permanent Exclusions

Permanent Exclusions are the ones that will never be included in any health insurance policy. Below is a list of diseases that are in the permanent exclusions list:

  1. Sarcoidosis
  2. Malignant Neoplasms
  3. Epilepsy
  4. Heart Ailment Congenital heart disease and valvular heart disease
  5. Cerebrovascular disease (Stroke)
  6. Inflammatory Bowel Diseases
  7. Chronic Liver diseases
  8. Pancreatic diseases
  9. Chronic Kidney Disease
  10. Hepatitis B
  11. Alzheimer’s & Parkinson’s disease
  12. Demyelinating disease
  13. HIV & Aids
  14. Loss of Hearing
  15. Papulosquamous disorder of the skin
  16. Avascular necrosis (osteonecrosis)

This is a comprehensive list of all the exclusions that are included under your health insurance policies. Do a thorough research if any disease is applicable to you and clear all your doubts with your provider before settling on a plan for you and your family. You can view the IRDAI circular here.

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