Avoid trouble with health insurance: Check your exclusions

Runjhun Noopur
Akosha is an online consumer forum

Have you ever been stuck in a situation, where despite having health insurance cover for yourself and your family, you had to bear the expenses for hospitalization of a family member?
There may be various reasons why an insurance company may reject your claim. Sometimes this rejection is valid since such a claim is specifically excluded in the policy document.
While these exclusions vary from company to company, based on our experience of dealing with consumer complaints, we have prepared an extensive checklist of some basic exclusions that most consumer get caught on.
So before you buy your policy, make sure you check for the following things:

• Pre existing diseases at the time of buying the policy are generally excluded.  Also complications arising from pre-existing diseases are usually considered a part of the pre-existing condition. 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.
• Certain diseases will be excluded in the first year of the policy. The basic premise of this exclusion is that insurance cover is not meant to protect you if you anticipate something happening in the near future. In other words, insurance, by design, cannot be strategic and essentially provides for unforeseen events or emergencies.
• Injury or disease caused by nuclear weapons is excluded. This of course is a distant possibility but good to know. Similarly, a less fantastic possibility of injury/disease caused by war is also usually excluded. Ask the insurance agent about what the policy says about terrorist events.
• Expenses on any disease or injury incurred during first 30 days from commencement of the policy are excluded. This clause, however, is not applicable on renewal of the policy. Also, in case of an accident, you will be covered.
• Pregnancy and childbirth is generally excluded from medical insurance policies. However in one of its significant verdicts, the Consumer Forum directed Oriental Insurance to bear the cost of treatment, given the circumstances of that particular case. If you are planning a family, make sure you check this exclusion before getting the policy.
• Cosmetic surgeries, cost of spectacles, cost of dental treatment are generally excluded from Mediclaim. Treatments other than allopathic (i.e. homeopathy, ayurvedic, naturopathy) are also excluded. Just check if psychological and physiological treatments will be included.
• Plastic surgery for cosmetic reasons is excluded. However plastic surgery on account of accident or illness is generally included.
• Expenses arising from treatment of HIV+ or AIDS are usually excluded. 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 you get a disease arising from reduced immunity?
• Medical expenses arising from misuse of liquor, drugs etc is also not included in the health insurance policy.

The basic idea behind this list is to ensure that every policy-holder is aware of such exclusions that are a part of standard industry practice and enable them to ask the right questions. In the long run, asking the right questions is sometimes the best way to avoid unwanted, unnecessary hassles.