It’s an amazing fact that in India over 514 million individuals were covered by a health insurance plan in the year 2021. (Source: Statista) But, have you ever faced a situation where you have health insurance covering you yet your claim is not being processed? This could be due to the standard exclusions and waiting periods outlined in your health insurance policy.
This is why it is imperative to check “what is covered” and “what is not covered” by the policy you’re going for. Since it is important to check on these two aspects, why not learn a bit more about what these are?
Importance of knowing about policy exclusions and waiting periods
In general, health insurance policies cover the majority of common illnesses; nonetheless, each health insurance plan has a unique set of exclusions. These exclusions are characterised as particular medical conditions or diseases for which no coverage is offered, or as some diseases that are only covered after a predetermined waiting period.
At the time of a medical emergency, not knowing about these exclusions or waiting periods can often lead to confusion and losses. Consequently, it is advisable to thoroughly read your policy documents before purchasing health insurance coverage and to be aware of the exclusions and waiting periods it specifies.
Now that we know why it is important to be aware of exclusions and waiting periods of a policy. Let’s explore some of the standard exclusions and waiting periods in a health plan so that you can choose the best health insurance in India.
Top 8 standard exclusions in a health insurance policy
- Waiting period clause
A waiting period is the duration of time after which certain illnesses are covered by your health insurance plan. The waiting period starts when the policy is issued and is also referred to as the cooling-off period. For example, the majority of health insurance policies contain a very common clause requiring a 4-year waiting period for pre-existing conditions.
If you submit a claim to the health insurance provider before the waiting time has expired, the insurer has the right to deny a claim. However, the insurance provider cannot reject a claim that you make after the waiting period has passed.
Types of waiting periods in health insurance plans
For pre-existing diseases (PED)
Pre-existing diseases are conditions that an individual has while purchasing health insurance, such as diabetes, high blood pressure, thyroid issues, etc. Pre-existing diseases are covered by almost all health insurance policies after a waiting period of typically two to four years. This means that any hospitalisation costs associated with such illnesses can only be reimbursed after four successful years with the insurance company.
For specific conditions/procedures
Certain mentioned conditions and treatments, such as ENT treatments, cataracts, osteoporosis, hernias, etc., usually have a one- to two-year waiting period under a standard health insurance policy. Only when the waiting period has passed will any medical costs associated with such diseases or procedures be reimbursed.
Initial waiting period
There is often a 30-day or one-month initial waiting period before any claims are processed, except for accidents.
For critical illnesses
Standard health insurance policies include a 90-day waiting period before covering critical illnesses, and any claims made during that time are rejected.
Permanent exclusions
Any health insurance policy will always exclude congenital illnesses and damages resulting from nuclear weapons and war.
Intentional injuries
Self-inflicted injuries and any diseases or injuries brought on by suicide attempts are not covered by a health insurance policy.
Mental illnesses
In general, health insurance policies do not cover mental health illnesses such as anxiety and depression. For more clarity, you can confirm the same with your insurance provider.
Maternity related expenditure
If you’re thinking about starting a family soon, check to see if your health insurance plan covers maternity-related costs, including childbirth or postnatal and prenatal care, newborn baby coverage, etc.
Most health insurance companies pay for maternity expenditures after a 1-2 year waiting period, so you can only use the benefit once the waiting period is over. However, it is advisable to carefully study the section of your policy document mentioning maternity expenses coverage.
HIV AIDS
The cost of sexually transmitted diseases (STDs) is not covered by a health insurance policy.
Cosmetic procedures
Cosmetic procedures including plastic surgery, breast implants, and body contouring are strictly excluded from standard health insurance plans.
Vision, dental and hearing
Despite some exceptions, dental and vision treatments are not covered by health insurance policies as they don’t require hospitalisation. But, if hospitalisation is unavoidable, it will be reimbursed by the insurer.
Thus, it is advised to inquire with your health insurance provider about the same. Anyhow, if you wish to enhance the coverage of your existing health insurance and make it the best health insurance in India, you can add these benefits as riders to your plan.
While choosing a health insurance plan, it is of utmost priority to take your time and assess your options. Evaluate your health requirements and those of your family, analyse what you want your plan to include, and then pick the best health insurance in India. Each health insurance provider has a unique list of exclusions. Therefore, make sure to carefully read through the policy documents before choosing a plan. If required, don’t hesitate to contact your insurance provider to learn what a certain plan will offer and cover. Just as it is important to know what is covered by your health insurance policy, it is equally important to know what is not covered by it.
Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.