Knowing what is covered and what is not in a health insurance policy is paramount to planning your health insurance and making the right pick. There is a list of 200 excluded items conditions specified by the IRDA which are segregated into nine categories. Insurance companies may include these exclusions in their health insurance products but cannot add any exclusion on their own.
IRDA Exclusions of Expenses
These have been specified by the IRDA, and all insurance companies take these exclusions into consideration while forming their health insurance policy wordings. IRDA has segregated the list of expenses excluded under nine categories and also has mentioned when the excluded items can become inclusive. The nine categories are:
- Expenditures on items of personal comfort or convenience
- Items specified as non-emergency for example obesity treatment, cosmetic surgery
- Non-payable hospital consumables
- Constituents of room charges
- Administrative and charges of non-medical nature
- External devices for support post hospitalization
- Non-payable prescription items
- Hospitals’ own internal cost items
- Other items considered as non-emergency
Pre-existing diseases are not covered under health insurance policies. However, insurers may provide for a waiting period of two to three years after which the pre-existing medical condition can get covered for expenses due to the same.
Internal Defects Diseases or Congenital diseases
Expenses incurred for treatment of diseases classified under internal defects or due to genetic causes (by birth defects) are not covered by health insurance policy. Such medical expenses can include treatment/operation for cataract, hernia, piles, fibromyalgia among others. These diseases do not have provision to become included after waiting period as per the IRDA. Expenses incurred for treating mental disorder are not covered under health insurance policy.
Convalescence or Run-Down Condition Treatment
If policy member or policyholder incurs treatment for overcoming convalescence condition or run-down condition then expenses for such treatment will not be covered by health insurance policy.
Certain Viral Diseases and AIDS Treatment
IRDA specifies diseases caused by certain viruses like HTLB-III and LAV as well as AIDS as not inclusive under health insurance policy.
Expenses Incurred on Diagnostic Tests
The IRDA specifies that health insurance policy will not provide cover for expenditures incurred on diagnostic tests and lab tests like blood sample test, MRI scan and other tests if such tests have taken for reasons other than covered condition occurrence treatment. If however upon being hospitalized due to the occurrence of a covered condition like accidental injury, organ failure and other covered conditions certain tests need to be taken during hospitalization for enabling the doctor to treat the covered condition then expenses over those tests shall be covered.
As per IRDA maternity and newborn baby expenses are excluded under health insurance policy. However, several insurers may include maternity and newborn baby expenses as policy riders so as to offer more comprehensive health insurance products to policy seekers.
Conditions Considered as Normal Ageing Problems
Expenditures incurred for treatment for normal age-related problems like painin joints, age-related macular degeneration and debilitation in physical strength due to the ageing of the body are not covered under health insurance policy.
Copayment and Deductible under Health Insurance Policy
If the policyholder has opted for the deductible in the health insurance policy, then the policyholder would need to bear the cost up to the deductible amount, and the rest shall be paid by the insurance company as co-payment agreement. The deductible feature is added to health insurance policy to make it more relevant to the policyholder. The policyholder may want to pay only premiums for cover considered relevant and may be ready to incur certain expenses by self.
Conditions Due to Self-Injury or Self-Infliction/Addiction
Health insurance policy does not cover expenses for treatment incurred due to conditions arising out of self-injury/infliction/addiction. No payment is made by the insurer if policyholder commits suicide.
Health Insurance Policy Riders
Policy riders are optional health covers. For example, there may be an accidental policy rider, critical illnesses policy rider, overseas coverage riders and other riders. Policyholders can make the rider options inclusive by opting for those while choosing their health insurance plans.
Tips to Save Most Through Health Insurance Plan
Health insurance policy offers substantial savings in expenses during times of medical emergencies as well as tax benefits under section 80 D. The following tips ensure that you get the maximum benefit through your health insurance plan:
- Claim tax exemption up to Rs 25 K p.a. for individual and family cover
- Claim additional tax exemption of Rs 30 p.a for senior citizen member cover
- Choose the riders as per requirements and needs of covered members
- Avoid acts of self-negligence, infliction or addiction
- Avoid acts of abnormal feats for getting maximum out of accidental health policy
- Avail NCB, renewal benefits and free medical checkup benefits