Buying health insurance? 11 exclusions you must know

Know when these come into play before buying a health insurance policy.

Have you ever been stuck in a situation, where despite having health insurance cover for yourself and your family, you had to bear the expense for hospitalising your old parents?

There may be various reasons why an insurance company may not honour your claim out of which some maybe valid and as per the company policy.

In this article we bring out the general exclusions under health insurance policies.

Coming back to the points to be discussed, there are certain standard instances where an insurance company may not reimburse the insurance money claimed by the consumer. However these exclusion clauses may vary from company to company.

Most important things to remember

What's excluded

Pre-existing diseases at the time of buying the policy will be excluded. Also complications arising from pre-existing disease will be considered part of the pre-existing condition. The insurance company may cover an individual after excluding the pre-existing diseases, if any. In the case of New India Assurance Co vs. Shantilal Balchandwhere the District Forum held that complainant's wife took treatment during the tenure of the policy and not before the policy was taken, and hence awarded damages to the complainant.

Why this could be important practically

A lot of diseases might go back a long way. Make sure you disclose what you already know. This is the single biggest problem in medical insurance claims.

What's excluded

Certain diseases will be excluded in the first year of the policy. In the case of Oriental Insurance Co. vs Pankaj Jain it was held that there is no deficiency in service if the disease is contracted within one year from the date of taking the policy.

Why this could be important practically

Again, insurance will not protect you if you anticipate something happening in the near future.

What's excluded

Injury or disease caused by nuclear weapons.

Why this could be important practically

Seems a distant possibility but good to know.

What's excluded

Injury or disease caused by war.

Why this could be important practically

Ditto. Ask the insurance agent about what the policy says about terrorist events.

What's excluded

Any expenses on any disease/injury incurred during first 30 days from commencement of policy, except those that are incurred as a result of accident.

This clause is not applicable on renewal of the policy. In the case of Bajaj Alliance Co Ltd vs Pradeep Sharma where it was held that complainant claimed reimbursement within 30 days from commencement of the policy; hence the Company was not liable to honour his claim.

Why this could be important practically

First 30 days are not covered by the policy.

What's excluded

Pregnancy and childbirth is excluded from the general purview of health insurance policy. However we have seen in the second case mentioned above that since the policy document did not explicitly exclude expenses related to child birth, the Consumer Forum directed Oriental Insurance to bear the cost of treatment.

Why this could be important practically

If you are planning a family, make sure you check this before getting the policy.

What's excluded

Cosmetic surgeries, cost of spectacles, cost of dental treatment are generally excluded from mediclaim.

Why this could be important practically

Self-explanatory

What's excluded

Treatment other than allopathy medicine (i.e. homoepathy, ayurvedic, naturopathy) will be excluded.

Why this could be important practically

Just check if psychological and physiological treatments will be included.

What's excluded

Plastic surgery arising out of accident or illness may be included. However plastic surgery on account of cosmetic changes to be made will be excluded.

Why this could be important practically

Always good to check this and understand what is included.

What's excluded

Expenses arising from HIV or AIDS will be excluded.

Why this could be important practically

This is very important. Check this clause with your insurer. Does it only exclude those who had AIDS at the time of the policy? What happens if you get it later? What happens if it is a disease arising from reduced immunity?

What's excluded

Medical expenses arising from misuse of liquor, drugs etc is also not included in the health insurance policy.

Why this could be important practically

Useful to check what happens if you have an accident while under the influence of alchohol.

Two recent cases

1. The South Mumbai District Consumer Disputes Redressal forum held the Insurance Company guilty when the consumer had disclosed the facts at the time of buying the insurance.

Facts of the case:

The complainant was admitted to the hospital for back operation as she was suffering from spondylosis. Insurance Company declined the complainant's claim on the grounds that she had not disclosed her previous health history at the time of buying the policy. However the complainant held that she had disclosed the fact that she had undergone treatment 12 years ago for similar problem. And that the Company had issued her the policy after knowing these facts.

Decision of the Forum:

The forum held the insurance company guilty and directed it to pay to the complainant Rs 1.33 lakh (treatment cost) along with Rs 10,000 as compensation for mental agony.

2. The Chandigarh UT District Forum held that insurance claim cannot be denied if consumer was not told about exclusions to the policy.

Facts of the case:

The complainant had bought health insurance policy from the Company for self and his family. His wife had to be treated for child birth. The Company rejected the insurance claim of the complainant on the pretext that maternity related treatment was excluded from the policy. The complainant held that the Company did not disclose to him about any exclusions at the time of buying the policy. In fact 'NIL' was written against the clause which stated any conditions, clauses, warranties and endorsements.

Decision of the Forum:

After reviewing the policy document, the Forum held that the Company was liable as it did not disclose to the complainant about exclusions to the policy. Hence the Forum directed the Company to pay Rs 25,300 as insurance claim plus Rs 25,000 as compensation and litigation cost.

Disclaimer:

Clauses mentioned here are general exclusion clauses and companies may include or delete clauses based on the company's policy. Every policy document shall mention the exclusions to the health insurance policy.

Our advice:

One should take utmost care and read the policy document carefully before signing the insurance papers.