Suppose you are planning to purchase a comprehensive health insurance scheme for yourself and your family. In that case, there are specific terms and conditions you must go through before making the final decision. One of the essential T&Cs that you as a policy buyer must-read is the list of exclusions in health insurance.

To begin with, exclusions are conditions that are not covered by a health insurance policy. This means that you cannot avail of the financial benefits of your health plans for the medical treatment or hospitalization for any of the mentioned exclusions. Every health insurer devises a healthcare plan with a certain list of conditions part of the exclusion list. This again depends on the insurer and the type of medical plan that you opt for. But the crucial part to take note of is that you must be aware of the exclusions, or else you might end up in financial stress during the time of claim!

In short,- A mediclaim policy does not cover every type of health condition that you would generally assume to do so. Where can you find the list of exclusions? Check your policy document and look for the topic that says ‘Inclusions and Exclusions.’ 

10 Common Exclusions in Health Insurance

To help you understand better, we will get straight to the point. Here is a general list of exclusions in a health insurance coverage plan.

Type of ExclusionDefinition – What Does it Mean?
Permanent exclusionAs the name suggests, this is not covered under your health plan by default. Certain conditions such as genetic disorders or life-threatening chronic diseases are categorised under this banner. 

Many insurers also have a specified list of diseases that are part of permanent exclusion.
Pre-existing disease (PEDs) or prior medical conditionsIf you already have a medical condition, sickness, or illness before buying a health policy, it will be considered as a pre-existing disease. It is not that all the pre-existing diseases are completely excluded from the scope of health cover. 
Out-patient department treatment (OPD)Many health insurance companies and providers in India do not provide cover for OPD. What is OPD? – Medical & health checkups, doctor visits & consultations, and regular diagnostic tests are categorised under OPD treatment. You can always buy OPD cover as a rider option to your base plan.
AYUSHTreatment for AYUSH (Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa, and Homoeopathy) is recognised as an alternative system of medicine in India. It is generally excluded.
Cosmetology Beauty treatments and cosmetics are not covered under any insurance scheme.
Maternity, Pregnancy, and ChildbirthThere is usually a waiting period applicable for maternity benefits. Newborn baby cover, pre and post-natal expenses, vaccination, and more are generally not covered but can be included as a rider option.
Standard  waiting periodThis is a general waiting period of 30-45 days after buying the policy. Insurers do not provide cover immediately post the date of policy inception (except for accidental related emergencies).
Intentional harmMedical treatment due to self-inflicted wounds,  suicidal tendencies, substance, and drug abuse is never covered.
Miscellaneous expensesCost of eating as per your preference during in-patient hospitalization, consumables not related to medicine, etc.
Lifestyle-related ailmentsThis includes diabetes, hypertension, obesity, and more. Such conditions are not covered because they can be managed with a proper and healthy lifestyle.
Critical IllnessesHeart attack
Cancer
Organ failure
Coma
Blindness
Neurodegenerative disorders
Transmission diseases – HIV/AIDs/STDs
Terminal illness
Paralysis
Certain psychiatric and psychological disorders

The above list is not exhaustive. It varies across different plans and insurers. 

Now that you know about the exclusions in health insurance, it is better to make it a regular practice to go through all the rules and regulations, terms and conditions, inclusions and exclusions before purchasing any insurance plan, especially health insurance cover. 

Are you still confused? Is there a way to cover pre-existing diseases in your health scheme? Yes, there is! Meet Plum Insurance here

Author

Growth Marketing at Plum Insurance