A health insurance plan aims to assist policyholders in covering the costs of availing treatment, hospitalization charges, and related expenses without depleting their savings. While having a health insurance policy in place is effective in securing one's financial future and preparing them for medical emergencies, not all of them are guaranteed to offer you claim money. Typically, such a situation can arise when a particular situation is not covered by the insurance or the same has been specified as an exclusion in the policy document. This makes it crucial for individuals to verify the exclusions before signing the document. Making sure that one reads the fine print about the exclusions in detail will help them make an informed decision and ensure that will get their claim approved when they need assistance.
Let us now discuss what health insurance exclusions include and why you should know them.
Why Should You Check Health Insurance Exclusions?
A policy document explicitly states all health insurance exclusions, which is why, it is recommended to read through the terms and conditions carefully. Having a clear insight into the terms helps understand what to expect from coverage, particularly during an emergency. It will also assist in determining if a certain insurance policy is enough to account for your requirements or whether it will fail to offer the insured their desired coverage.
Individuals may gain a proper understanding of the common exclusions by comparing major health insurance policies, which will assist in purchasing a suitable plan with high coverage. As a result, individuals will be better prepared for the exceptions included in most popular policies.
Common Health Insurance Exclusions
Exclusions are basically legal constraints under which an insurance provider is not obligated to settle the insured's claim. Individuals should note that standard and non-standard policies come with exclusions that can take many forms. Exclusions can often influence the scope of insurance coverage.
These are among the most common exclusions of health insurance plans -
1. Existing Illnesses
A pre-existing illness can be described as a medical condition that an individual has before they obtain a health insurance policy. The list of covered pre-existing illnesses and the waiting period to raise a claim can vary among insurance providers.
Note that some pre-existing illnesses, including diabetes, thyroid, and hypertension, may be covered under a few health insurance policies, but only after a specified waiting period. Help pick a policy that accounts for your existing health issues to have a comprehensive financial plan to rely on and eliminate the need to dip into the best retirement plans or savings account in future.
2. Illnesses andSurgeries
Health insurance plans offered by different providers tend to vary in their coverage and approach when it comes to certain chronic illnesses and procedures. For example, some of the most common exclusions include hernia, cataracts, mental illness, bariatric surgery, and joint replacement surgery. Notably, even if a surgery or illness is covered, the insured will have to wait for some time before the benefits can be claimed. This waiting period for health insurance can extend from a few days to years, as per the policy. It is also crucial to review chosen health insurance policies to ascertain what is covered and what is exempted. Individuals can contact their insurer if they have any doubts about their coverage or exclusions and avail of accurate advice before getting a policy.
3. Diagnostic and OPD Treatment
Health insurance plans typically do not cover diagnostics charges or the cost of OPD treatments. However, a few insurance providers offer policy buyers add-on OPD treatment and diagnostic covers in their base plans. This allows policyholders to gain access to essential Medicare without paying out of their pocket.
Individuals should note that the cost of these rider covers varies based on the insurance and the chosen policy, and adding them to an existing plan can inflate the premium. However, these add-ons can be a useful way to avail protection against the cost of medical care. When looking for an insurance plan, make sure to find out more about OPD and diagnostic covers.
4. Pregnancy and Childbirth
Standard health insurance policies usually do not cover the expenses of pregnancy and childbirth. Individuals should note that maternity expenses are coveted under add-on to regular health insurance. However, they should remember that these add-ons may come with a waiting period ranging between 1 and 2 years, during which they cannot claim maternity-related expenses. This makes it vital to choose a maternity add-on with a short waiting period. Additionally, infertility treatment and abortions may not be covered by policies.
5. Cosmetic Treatment
Cosmetic surgeries are not covered by comprehensive health insurance policies, as the procedures are perceived as elective measures that are not necessarily essential. However, if a cosmetic procedure is deemed essential to rectify a congenital defect or enhance a body part’s function, then it could be covered by a policy. If such a surgery is administered as part of a medical procedure then the insured can be entitled to claim settlement.
6. Adventure-related Treatment
Health insurance covers charges that are typically incurred to treat injuries caused during adventure sports, given the sports are not practiced professionally and were conducted under the keen supervision of a professional. For instance, injury during rock climbing would be covered, but injury during a professional rock climbing event will not be covered.
7. Permanent Exclusions
These entail congenital diseases, self-inflicted injuries, war-inflicted injuries, and any injury caused during suicide attempts. Note that substance abuse and addiction are permanently excluded from coverage. A few examples of such exclusions include expenses arising during treatment of the accidental injury caused due to misuse of drugs, opioids, alcohol, etc., or during the treatment of deaddiction charges.
Having an idea of these exclusions when looking for and comparing insurance policies can help individuals pick the plan with fewer exclusions. With these exclusions, individuals should also find out the policy provider’s claim settlement ratio and determine the steps of the claim process to ensure their future claims will be approved in times of need. It is often recommended to opt for an insurance policy provider with a claim settlement ratio of over 85%. A higher number suggests a higher claim settlement.
