List of Common Exclusions in a Health Insurance Policy

Why Should You Check Exclusions Before Buying Health Insurance?

Exclusions in health insurance refer to diseases, medical conditions, treatments and specific circumstances that are permanently not covered or covered after a waiting period. Your insurance company is not liable to pay for diseases or things listed as exclusions in your mediclaim policy. Raising a claim for medical conditions or treatments excluded from your policy will lead to its rejection.

Health insurance exclusions and limitations are not the same across all insurers. Although IRDAI has issued a list of permanent exclusions in health insurance, insurers can offer coverage for a disease/treatment after a waiting period or on payment of an additional premium. For example, several plans do not cover non-medical expenses, but some of them may offer consumables cover as an add-on.

Hence, you must check the exclusions before purchasing a mediclaim policy to know exactly what your insurer will not pay for. Doing so will save you from any disappointments and financial distress at the time of claim settlement.

16 Common Exclusions in Health Insurance

Check out some of the most common exclusions in health insurance:

1. Waiting Period Clause

   All health insurance plans in India come with a waiting period clause. As per this clause, all health plans have an initial waiting period of 30 days and a specific disease waiting period of 1-2 years. During this waiting period, your insurance company will not accept any claims except for accidental claims. Thus, you cannot file a claim with your insurer unless your waiting period is over.

2. Pre-Existing Diseases (PED)

   A pre-existing disease refers to the medical condition you were diagnosed with before buying a health insurance policy. All medical insurance plans in India cover pre-existing diseases after a waiting period of up to 3 years. This means your pre-existing diseases are excluded from your policy unless your waiting period is over.

   PRO TIP: Many health plans now offer pre-existing diseases coverage from day 1.

3. Pregnancy and Childbirth

   Medical expenses incurred due to pregnancy and childbirth, such as delivery charges, pre & post-natal expenses, abortion, miscarriage, etc., are not covered under most health plans.

   PRO TIP: You can opt for a maternity insurance benefit as a rider or add-on cover to get your pregnancy costs covered. Moreover, you can also get your newborn baby’s treatments and vaccination charges covered under the maternity cover.

4. Non-Medical Expenses

   Non-medical expenses incurred during hospitalization, such as needles, syringes, cotton, bandages, gloves, sanitizers, masks, gowns, PPE kits, etc., are excluded under most medical insurance plans.

   PRO TIP: You can get different types of non-medical expenses covered under your health policy by opting for consumables cover on payment of an additional premium.

5. OPD Treatments

   Most mediclaim insurance plans do not cover outpatient department (OPD) expenses, including the cost of doctor consultations, medicines and diagnostic tests.

   PRO TIP: You can opt for an OPD cover as a rider or add-on to get your OPD expenses covered.

6. Dental Treatments

   Dental treatment expenses are not payable under most health insurance unless resulting from an accident.

   PRO TIP: You can opt for a dental insurance plan to cover the cost of your non-accidental dental treatments.

7. Obesity Treatments

   Most mediclaim policies do not cover the cost of obesity treatments and bariatric surgeries, such as sleeve gastrectomy.

   PRO TIP: Some health plans come with bariatric surgery cover that can pay for the cost of your weight-loss surgery if recommended by a doctor.

8. Cosmetic Surgeries/Plastic Surgeries

   Cosmetic surgeries and plastic surgeries are not payable by health insurance companies in India unless resulting from an accident.

9. Infertility Treatments

   Most insurance companies in India do not cover the cost of infertility treatments, such as IVF, assisted reproduction treatment, artificial insemination, etc.

   PRO TIP: Some insurers now offer coverage for infertility treatment under their plans, especially women health insurance plans.

10. Sexually Transmitted Diseases

    Sexually Transmitted Diseases (STDs), such as syphilis, and venereal diseases are listed as permanent exclusions in health insurance.

11. Dietary Supplements

    Medical expenses incurred on dietary and health supplements are not payable by insurance companies in India.

12. External Congenital Diseases

    Any medical expenses or treatments resulting from external congenital diseases, such as Down syndrome, cleft lip, clubfoot, etc., are not covered under mediclaim insurance plans.

    People also read: Does Health Insurance Cover Congenital Diseases in India?

13. Non-Allopathic Treatments

    Non-allopathic treatments, such as naturopathy, acupuncture, etc., are not covered by medical insurance plans.

14. Treatments for Excess Consumption of Alcohol or Drugs

    The treatment cost of diseases or injuries resulting from excess consumption or addiction to alcohol or drugs is permanently excluded from health insurance in India.

15. Self-Inflicted Injuries

    Any medical expenses arising out of injuries made deliberately, such as suicide or an attempt to suicide, are not covered by health plans.

16. War & Related Perils

    Medical insurance plans also do not cover the medical expenses incurred on treating injuries or diseases resulting from war or related perils.