Health insurance is a long term policy, which covers necessary hospitalization for accidents and sickness till your old age, and in many cases for your lifetime.
Since the policy is for the long term, there are some hurdles primarily created to discourage buying the policy for the purpose of “planning” a claim in the short term. The hurdles are in the form of waiting periods in short term of 1, 2 and 4 years, after which the policy gradually “opens up” to a much wider cover.
There are 3 kinds of waiting periods in the policy, which one should know:
1. 30 Day Cool-off Period:
Conditions/Ailments first diagnosed in the first 30 days of the policy are not covered under the policy.
2. Exclusion on Specified Surgeries:
The policy opens up cover for the following surgeries from the 3rd year:
ENT Disorders, Surgery of Hydrocele (male scrotum), Hernia, Arthritis, Cataract, Enlarged Prostrate BPH Surgery, Hysterectomy, Fistula in Anus, Piles, Sinus, Gallbladder surgery, Surgery of the Genito-Urinary System, Pilonidal Sinus, Gout, Rheumatism, Hypertension, Diabetes, Stones, Slipped Disc, Varicose Veins, Joint Replacement, Osteoarthritis, Osteoporosis.
All symptoms, diagnosed ailments, health conditions declared/undeclared have a minimum waiting period of 4 years, after which they are covered. In certain conditions there are co-pays after the waiting period. For certain critical ailments the Pre-existing condition could be permanently excluded.
Other than the above waiting periods in the policy, the policy permanently excludes some other treatments.
Permanent Exclusions in the policy:
- Hospitalization only for evaluation purposes.
- OPD treatments.
- Maternity and Childbirth expenses
- Dental expenses, except for Dental surgery required due to Accidental Surgery.
- Cosmetic Surgeries.
- Rehabilitation treatments, which cure by rest, also called “Rest Cure”
- Unproven treatments like Acupressure etc.
- Surgery for Correction of Eye Sight – Lasik, is not covered.
- Accidents caused by hurting own-self, due to alcohol or drug abuse, adventure sports.
- Treatment for psychosomatic, psychiatric disorders.
- Treatment of HIV.
- Sexually transmitted diseases.
- External Medical Equipment.
- Genetic Disorders.
- Treatment of Obesity.
- Service Charge, Registration Charge in a Hospital.
Most of these treatments are cosmetic, or predictable, and hence, are made to discourage the policy, being bought only to claim for such treatments. Note, the premium you pay is based on exclusions of such treatments, without which the premium would not have been as affordable as they are.
Finally, your policy could have limits/capping, which could limit how much you could get for your hospital bills:
Room Rent Limits:
Your Policy could have limits on how much you can claim on Room Charges in the Hospital. In some new policies, the limit could also be related to the category of room you can select. Also, note, since almost all expenses in a Hospital, are linked to the room category, you will be paid all expenses according to the eligible category of room. For instance if your room rent limit is Rs. 3000, which provides you a Shared Room, all charges would be paid in the claim, as per the Shared room tariff of the hospital. In absence of a tariff, this would be paid proportionately.
Sub Limits on Surgeries:
Some Insurance Companies could apply limits to specific surgeries. For these treatments, the policy would pay only up to this limit.
Co-pay is the share of the admissible claim, which you are required to pay in the policy. If your policy has a co-pay of 30%, and if your final payable claim amount, as per the policy conditions is Rs. 100, you will be paid Rs. 70/- by the Insurance Company, and you will have to bear Rs. 30 in addition to the amount deducted due to limits and exclusions in the policy.
Remember, this is not an exhaustive list. This article has been written to provide you with a brief idea of what are the kinds of exclusions present in a health insurance policy. Request you to refer the “policy wordings”, for the entire terms and conditions.