What are the Diseases Not Covered Under Health Insurance?

What are Exclusions in Health Insurance?

In health insurance, "exclusions" are specific conditions, treatments, or services that your insurance policy does not cover in accordance with the guidelines set by Insurance Regulatory and Development Authority of India (IRDAI). This means if these excluded situations arise, insurer might reject your claim and eventually you will have to pay for the costs out of pocket.

While buying a mediclaim insurance, it is important to research properly as it will help you choose a health policy that has minimal exclusions and offers maximum coverage. Furthermore, medical plans generally exclude certain diseases from the first year of coverage and cover it once the waiting period is over.

List of Diseases Not Covered Under Health Insurance

Following is the list of diseases not covered under health insurance India:

1. Pre-existing Diseases

   Pre-existing diseases refer to any illness that you have at the time of buying a health plan. Some medical insurance companies may provide coverage for pre-existing diseases like diabetes, blood pressure, etc. but most of them cover such expenses only after the waiting period is completed, which can range from 12 months to 36 months. However new health plans are being launched that provide PED cover from Day 1. Moreover, in some cases, the insurer covers pre-existing diseases on payment of additional premium.

2. Epilepsy

   Health insurance policies often exclude coverage for epilepsy. This means if you have this condition or develop it later, the costs for doctor visits, diagnostic tests, medications, or treatments related to epilepsy might not be covered. You would need to pay for these expenses out of pocket.

3. Sexually Transmitted Diseases (STDs)

   STDs, also known as venereal diseases, are the diseases that are primarily spread through sexual contact such as syphilis, HIV/AIDS, etc. Though these conditions may require ongoing medical care but many health insurance policies exclude coverage for these illnesses. This means that if you are diagnosed with an STD, the costs for managing the condition would not be covered by your insurance company.

4. External Congenital Conditions/ Birth Defect

   Health insurance does not typically cover the treatment of medical conditions present from birth that are external in nature. Some of the common examples include Down syndrome, cleft lip, etc. Any costs related to treating or diagnosing such conditions are excluded from standard health plans.

List of Things Not Covered Under Health Insurance

The list of things that are not covered under a mediclaim insurance policy is as follows:

1. Dental Treatment

   Most medical insurance policies do not cover expenses for routine dental care procedures unless they are necessary due to injuries caused by an accident.

2. Injuries Related to Overconsumption of Alcohol

   If any injury is tracked to overconsumption of alcohol like liver damage, and other problems, then the insurance company holds the right to reject your health insurance claim.

3. Infertility/Pregnancy Related Complications

   Hospitalization expenses related to infertility/pregnancy complications like abortions are excluded from health insurance coverage. In some maternity health plans, these expenses can be covered, but in basic mediclaim policies, these expenses are not covered. You can check your policy wordings if you are specifically looking for coverage for pregnancy-related expenses. You can also check out women specific health plans to cover such expenses.

4. Weight Loss Surgery

   Most health insurance companies in India do not provide coverage for expenses related to bariatric or weight loss surgeries. This can include procedures such as gastric bypass, sleeve gastrectomy, etc. However, some health plans or insurers may cover weight loss surgery if it is deemed medically necessary.

5. Cosmetic/Plastic Surgeries

   Cosmetic surgeries, commonly known as plastic surgery, like botox, implants and similar surgeries are excluded from a health insurance policy. You can check with your insurer if you plan to go through any such surgery during your health insurance policy term. Unless it is a part of the treatment, health insurance companies do not compensate for such medical procedures.

6. Self-inflicted Injury/Suicide

   Injuries that occur due to self-inflicted harm, such as those resulting from a suicide attempt, are excluded from medical insurance coverage. Health insurance companies do not settle any medical expenses incurred to treat such injuries.

7. Consumable Expenses

   Items like needles, syringes, cotton, bandages, gloves, sanitizers, masks, and PPE kits used during hospitalization are often categorized as consumables. These are not included in the standard health insurance coverage. However, you can purchase a specific add-on known as a "consumable cover" to ensure these costs are covered under your mediclaim policy.

8. Expenses Incurred on Non-Allopathic Treatments

   Any expenses that you incur on non-allopathic treatments like Naturopathy, Homeopathy, Ayurveda and similar treatments are excluded from health insurance coverage.

9. Dietary Supplements

   Under your medical insurance policy, the insurance company does not provide financial cover for health tonics and supplements. If these are recommended by the treating doctor, then the expenses might be claimable. But if you are taking it without any prescription then it shall not be a part of policy coverage. For details, you can refer to the policy wordings.

10. War and Related Risks

    Injuries caused by situations like wars, terrorism, military conflicts, or related events are not covered under health policies. This includes injuries sustained during civil unrest or participation in violent activities.