A Convenient Guide to Everything You Need to Know about Exclusions in Health Insurance

Have you heard of the term exclusions in health insurance? If you are buying a health policy for the first time, this is a very important term you must know. It makes a lot of difference to what you could pay for your health policy. 

Yet, no one likes to read a long terms and conditions document in tiny font. We understand. This blog will help give you a quick overview of exclusions in health insurance. We can’t promise you will be an expert, but we are sure you will know enough to make the right choice when picking a health insurance policy.  

It is very important you fully understand exclusions in health insurance before picking a policy. Not only will it determine your out of pocket costs, but can also affect your chances of claiming a reimbursement if you file for things that are not included in your health insurance.  

Exclusions in Health Insurance 

Exclusions in health insurance are basically medical conditions or healthcare expenses that are not covered by your insurance company. For all these expenses, you will have to pay for them yourself. That holds true even for employees who are on a group health insurance plan.  

Exclusions in health insurance can be broadly classified into two types – variable and fixed. Variable exclusions (or specific exclusions) are those that differ from policy to policy. These are the places you should be really careful about, since it can help you save money. 

Whether you are getting a personal health policy or employee group medical insurance, it is always wise to find a policy with as few exclusions as possible. That way, you ensure you get the most out of your health policy, without having to pay from your pocket.  

Fixed exclusions (or general exclusions) on the other hand are those which are standard amongst all policies. These general exclusions can cover things like diseases/injuries caused by war or radiation, cost of spectacles and hearing aids, cosmetic surgeries, and treatments conducted on a trial or experimental basis.  

Examples of exclusions in health insurance

Some Popular Exclusions 

As mentioned previously, these are exclusions that vary from policy to policy. The ideal health insurance policy won’t have any such exclusions, but you won’t find such a policy. Each health policy will have a list of specific exclusions, depending on your premium amount.  

Here’s a look at some common exclusions in health insurance you might find-

  • Pre-Existing Diseases: Pre-Existing diseases are conditions that an individual has before he/she purchased a health insurance policy. Diseases can range from high blood pressure to diabetes. Not all insurance policies cover such cases, meaning any hospitalization from such a disease cannot be claimed. Some policies offer claims for such conditions, but with a waiting period anywhere between 2-4 years or no waiting period at all in some group health insurance policies.  
  • Dental Treatments: Normally, dental treatments aren’t covered by an insurance policy. However, some dental procedures can be claimed in case they are necessary due to an accident. The same goes for hearing, cosmetic and vision-related treatments.  
  • Alternative treatments: Almost all health insurance plans today offer claims for allopathic treatments. There are, however, a few policies that support alternative systems like Ayurveda, homeopathy, and naturopathy. Check for AYUSH coverage if you want to avail insurance for such alternative systems. But you should know some plans offer AYUSH coverage with a sub-limit, so be sure to check carefully.  
  • Pregnancy and Childbirth: Expenses related to pregnancy and childbirth are also considered exclusions in health insurance policies. If you plan to have a child, this is one exclusion you cannot afford to ignore. Look for policies that cover these expenses otherwise you could end up paying a lot. 
  • Administration Charges: Almost no insurance policy covers administration charges. You will have to pay for things like admission costs, discharge costs, visitor passes, and name tags. Other costs that aren’t covered include laundry charges, toiletries, convenience items, bandages, gauze, gloves, masks, etc.  
  • Injuries due to Attempted Suicide and Lifestyle: Insurance companies don’t tend to cover the costs of treatments due to attempted suicide or lifestyle-related diseases. That includes liver cirrhosis due to excessive drinking and lung damage due to smoking. In case you are hospitalized due to such conditions, you will have to pay for the full cost of treatment yourself.  

That list is not exhaustive. There are plenty of other exclusions in health insurance, depending on the insurance company. The best and only way to truly know what you are covered for is to read the full terms and conditions document. Another reason you should read is to know if diseases like cancer are covered, or if you need to purchase a top-up to your existing policy. 

Whether you are purchasing a policy for yourself, your family, or your employees, be sure to find one that has a small list of exclusions. The smaller, the better. As an employer, are you looking for comprehensive employee healthcare plans with group health insurance benefits for your team? If so, why not check out the Onsurity Plus membership? Onsurity’s healthcare benefits for employees offer a wide range of benefits along with a comprehensive group health insurance plan for members by our insurance partner. With few exclusions, it is the best option for your team and their families.  

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