What are exclusions in a Health Insurance policy – Importance of knowing exclusions while purchasing a policy

Exclusions are the incidents, medical condition, damages or expenses which are not covered under your insurance policy. Any damages or losses arising out of what is particularly mentioned in the policy documents as exclusions will not be covered and you have to bear any such expenses from your own pocket.

You are your own insurer for that part of risk and in the language of risk management, the risk which is excluded under the insurance policy is to be retained by the insured.

Health insurance also has its own set of exclusions and any customer should read the policy terms and conditions to know that what is actually covered under the insurance product and what is not. This is important, as the policyholder knowing the exclusions from the very beginning will be financially and mentally prepared to bear the medical expenses for any event if that is excluded in insurance.

It is highly advisable to thus read and understand the exclusions very carefully at the time of policy purchase only and immediately consult your agent or customer service department of the insurer if there is any confusion, this helps to eliminate any unwanted surprises at the time of the claim.

Every health insurance product will definitely have some common and may have some different or particular set of exclusions and in this article, we will discuss below some exclusions with explanations which a health insurance product may have.

Readers kindly note that for any health insurance product you want to purchase and from any insurer, the policy wording and other documents with all terms and conditions are available in the download section at the website of the respective insurer, which you should download and read for a better understanding of your policy.

  1. Waiting Period: This is only applicable for first time policy takers and not for people renewing their policy or switching insurer. In general, there is a waiting period of 30 days to 90 days for any claim, varying from insurer to insurer and product to product, after first time taking the policy, which is like a time excess and any hospitalization or other claim will not be covered within first, say 30 days of the inception.

There may be separate waiting periods for some coverages like pre-existing diseases will have longer waiting period of say 36 months. No coverage for any pre existing diseases will be provided till a continuous period of 3 years has been elapsed. Similarly, maternity (If covered) will also have longer waiting periods. Critical illness if covered by your policy may have a waiting period of e.g. 30 days.

  1. Maternity and child-birth expenses are excluded from some policies. Thus, for bachelors and newly married couples who are planning for a baby, it is advised to duly confirm that your policy covers the same. Other coverages that such people can check are new born baby cover and Pre- and post-natal cover which can be excluded in policies excluding maternity benefit.
  2. Any treatment for substance or drug abuse or any injury arising out of the same will be excluded from the scope of a health insurance policy. Also, in some health and critical insurance policies there is a need to declare that no alcohol or tobacco usage is there for the policyholder, you claim may be excluded at a later stage if you give false declaration.
  3. Many health policies exclude dental treatment and surgeries unless requiring hospitalization due to an accident.
  4. Birth control may be excluded e.g. contraceptive pills or devices and sterilization. Circumcision is generally excluded unless necessary for treatment of an illness or due to an accident. Infertility or any form of assisted reproduction is also excluded from scope of insurance. Similarly, treatment of sexual dysfunction or complications arising from change of sex will not be covered.
  5. All health policies will exclude sexually transmitted disease like AIDS/HIV and ARC (AIDS related complex). Very rarely some policies may cover the same if specifically mentioned in wordings.
  6. Any cosmetic treatment which changes appearance or weight loss surgery like bariatric surgery is excluded from almost all health insurance products.
  7. Injury from adventure sports or defence operation, war and hazardous substances, breach of law with criminal intent, self-inflicted injury or any items of personal comfort and convenience, spectacles and hearing aids will be excluded from all insurance policies.
  8. Unproven or experimental treatment, Unrelated expenses, vitamins and nutritional supplements are excluded. Some specific treatments like diagnosis and treatment by manipulation of the skeletal structure is excluded from health insurance.
  9. Cost of treatment of any sleep disorder and sleep problems like insomnia, sleep apnoea will be excluded.
  10. Psychiatric treatment is generally excluded.
  11. Developmental delay in children like ADHD, speech, Mobility, learning etc are not covered in the policy.
  12. Prosthetic and similar devices which are not internally implanted by surgery is excluded.
  13. Your policy may have an exclusion for alternative therapies. Check for the same if your policy covers AYUSH benefit, which is covered nowadays in many products.
  14. Congenital diseases are excluded
  15. Additionally, one must check for any sublimit, co-payment, excess or deductible applicable in the health insurance policies. These are also a sort of exclusion as the cost needs to borne from the insured’s pocket and insurance company will not step forward to make good of these costs.

IC – 01 Principles of Insurance – MCQ’s: Licentiate Exam

MCQ’s on General Insurance Licentiate Exam : IC 01 / IC 11 / IC14 (Total 300)


Sharing is caring!