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Common Exclusions in Health Insurance

A health insurance policy is not just a benefit but a necessity that comes as a saviour in medical emergencies. It provides a financial cushion during a medical crisis and pays off the medical bills that would otherwise hit savings.

While the health insurance policies cover most medical conditions, there are a few “exclusions” that might come as a surprise to us if we aren’t aware of them.

Rather than realising later that your expensive dental treatment wouldn’t be covered by your insurance provider, it’s always better to understand and know about all the exclusions in your health policy.

What is Meant by Exclusions in the Health Insurance Policy?

“Exclusions” with respect to Health Insurance are certain kinds of medical conditions that are not covered by the Health Insurance Policy or, in some cases, are covered after certain period

Team Digit

What are the most Common Exclusions in Health Insurance?

The complete list of exclusions might differ from one policy to the other.

While some of them might be covered after a certain waiting period in health insurance, some common conditions are permanently excluded under health insurance across the industry.

Let's have a look at some of the most common exclusions:

1. Pre-Existing Diseases

Any medical condition that the insured is suffering from at the time of taking the policy is known as Pre Existing Disease. It is not covered under health insurance. However, some of these might be covered after a certain waiting period.

A few examples of these Pre-Existing Diseases are Diabetes, thyroid, Hypertension etc.

Check: PED Cover in Health Insurance

2. Specific Diseases or Procedures

Certain diseases like cataract, Hernia, Psychiatric Illness and Disorders, Joint Replacement, Bariatric surgery etc. are covered after a certain specific waiting period in Health Insurance.

3. Pregnancy and Childbirth

Many standard health insurance plans do not cover Pregnancy and Childbirth, i.e. Maternity Expenses, which is usually taken as an add-on with individual health insurance. However, even in such cases, it usually has a 2- 4 years waiting period.

Similarly, the treatment for infertility and abortion cases is not covered under most health insurance policies.

With Digit’s Health Insurance, you can avail coverage for Maternity, Child Benefit, Infertility treatment and Medically Necessary Terminations through its additional cover.

4. Cosmetic Treatment

Any form of cosmetic treatment like plastic surgery to enhance looks is not covered under the health insurance policy. This might be because cosmetic treatments are not indispensable to maintaining a human's life and are thus not considered necessary. However, when a cosmetic treatment is medically necessary and requires hospitalisation for the same, like after an accident, it is generally covered in the health insurance policy.

5. Diagnostic Expenses and OPD Treatment

Though their importance in any treatment process is undeniable, health insurance plans usually do not cover the diagnostic expenses.

Also, OPD treatments are not covered in most of the health insurance policies. However, some insurance companies, alternatively provide OPD insurance plans that cover both the above situations i.e., OPD treatment and diagnostic expenses, mostly as an add-on benefit that can be taken with their regular health plan.

6. Hazardous or Adventure Sports related treatment

Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports is not covered.

Hence sports like para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving fall under exclusions if done professionally.

However, you would be covered if you participate in a non-professional capacity for any recreational sport which may be under the supervision of a trained professional.

7. Permanent Exclusions

There are some permanent exclusions in Health Insurance like Injuries in War, Intentional or self-inflicted injuries, injuries due to suicide attempts and congenital diseases.

8. Substance abuse and Addictions by the Insured are excluded in below cases

Expenses incurred for the treatment of any Illness or accidental Injury caused due to:
Use/misuse/abuse of Alcohol, opioids or nicotine or drugs (whether prescribed or not) by the Insured unless associated with Psychiatric Illness.
Withdrawal and de-addiction treatment taken by the Insured.
Any claim in respect of Cancer of Oral, Oropharynx and respiratory system is specifically excluded in cases where Insured is a tobacco user.

As much as it is indispensable to have a health insurance policy, however, it is equally important to know about the policy entirely before signing for one. Consider your and your family’s health needs and make a complete analysis of the requirements. Thereafter opt for a health policy that appropriately fits your requirements.

Every insurance provider has its own set of inclusions and exclusions. However, as discussed above, some exclusions remain largely common across most providers. Before choosing a plan, always go through the policy document to make an optimised selection and an informed decision. This will help you to be better prepared for medical emergencies.

For more information regarding exclusions please refer to your Policy Document.

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Go Digit General Insurance Limited (formerly known as Oben General Insurance Ltd.) - Registered Office Address - 1 to 6 floors, Ananta One (AR One), Pride Hotel Lane, Narveer Tanaji Wadi, City Survey No.1579, Shivaji Nagar, Pune-411005, Maharashtra | Corporate Office Address - Atlantis, 95, 4th B Cross Road, Koramangala Industrial Layout, 5th Block, Bengaluru-560095, Karnataka | Trade logo of Go Digit General Insurance Ltd. displayed above belongs to Go Digit lnfoworks Services Private Limited and is provided and used by Go Digit General Insurance Ltd. under license.