Know the exclusions in Health Policy

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Health Plans have become popular after Covid 19 as it has brought the awareness and the need of Mediclaim for the family. The limitations of the policies have also come in highlight as many got caught into a situation where inspite of the policy the insured had to shell an amount from the pocket. Our previous newsletter where we had covered such areas which can make you pay you for the shortcomings your policy has eg Room rent capping, capping on diseases. Etc. However, it is equally important to take a note of exclusions too in the policy as it would lead to denial of the claim; 

  1. Exclusion of Waiting Period- We had covered the subject in detail in our last edition where we highlighted all policies have 2 waiting period- 24 hour and 24 months. Except accidental claims no other claim is payable, similarly, some of the ailments like Hernia, cataract, neuro and many are not covered for period of 24 months from the date of inception of the policy. Read the article here: -

  2. General Medical Exclusion- Treatment for alcoholism, drugs or any addictive condition, day care procedures which aren’t  listed or not serious in nature like Plaster in case of fracture, getting bandage of stitches for any wound, severe sleep apnea including machine required, expenses related to enforced bed rest, Reversal of sterilization, peritoneal Dialysis, mental disorder, Cosmetic Surgery, Parkinson and Alzheimer’s disease and many such diseases which might has its own severity but aren’t covered in the policy.

  3. Non-Medical Exclusion- These are the exclusions which aren’t linked with the ailments and could be linked to the activities one is involved. The examples for such exclusions could be for Defense personals that are at war or at war like situations. For insured who is involved in Naval, military or air force operation, racing, diving, aviation, scuba diving, parachuting, hang-gliding, rock or mountain climbing. Anyone committing or attempting to commit a breach of law with criminal intent Intentional self-injury or attempted suicide. Charges incurred at a Hospital primarily for diagnostic, X-ray or laboratory examinations Doctor’s fees charged to his immediate relative of an Insured Person’s family. Any treatment or part of a treatment that is not of a reasonable charge, not medically necessary; drugs or treatments which are not supported by prescription. Any claim incurred after date of proposal and before issuance of policy where there is change in health status of the member and the same is not communicated to Insurance Company. Lastly, many times Insurance companies notifies of exclusion for some time during a period, however, only with approval of Regulator.

    The above exclusions have to be kept in mind while one lodges his claim as you might get caught unaware of the conditions which can lead to denial of the claim. However, for the cases of porting the policy where the insurance company accepts the case the condition of preexisting and waiting period is waived as it’s ported with the continuity from previous policy. We would strongly advice that one should seek help of your advisor or agent or broker from whom you have bought policy from as some critical areas could be handled by an expert at initial stage of claim.