Diagnosis & Observation
If you’re admitted to the hospital just for diagnosis and evaluation, then the expenses will not be covered by health insurance.
For instance, Savio has some pains in his chest and visits the hospital. The doctor does a basic routine check and tells him to get admitted. While he’s in the hospital, the doctor gives him some medicines and conducts some tests.
Other than this, no treatment is carried out - and he is discharged the next day. The insurance company will not cover the expenses incurred by Savio in this scenario.
Expenses related to pregnancy, childbirth, pre and post-natal costs, etc. are generally not covered under a health insurance policy. You, however, can opt for the Maternity Benefit with your base policy if you want your health insurance to cover expenses related to maternity.
Obesity/ Weight Control
If you undergo any treatment primarily for obesity or to control your weight, the insurance company won’t cover the expenses.
Drugs & Narcotics
The treatment for any illness or injury arising out of excessive drug use, alcoholism, etc. is permanently excluded by insurance companies.
Any expenses incurred when the medical procedure is carried out in the outpatient department are excluded permanently.
Suppose Ananya falls down the stairs, damages her right leg, and her toes begin to bleed. Her sister drives her to the hospital. The doctor tells Ananya’s sister to take her to the Outpatient Department. After some time, a nurse cleans and treats the wound. The doctor then prescribes some painkillers and tells Ananya to rest at home for a few days.
Because Ananya’s wound was treated at the Outpatient Department, health insurance will not pay for the expenses.
Change Of Gender Treatment
Health insurance will not cover any treatment expenses that are carried out to change the characteristics of the body to those of the opposite sex.
Cosmetic/ Plastic Surgery
The costs of medical procedures that are undergone to change/ enhance your looks or appearance, etc. are not covered under health insurance.
For instance, breast or lip augmentation, hair transplantation surgery, rhinoplasty, etc. are not covered.
The cost of treatments or surgeries for any illness or an injury that is not yet proven is not covered under health insurance.
Profession In Risky Or Adventure Sports
If you're professionally engaged in risky and adventurous sports, such as para-jumping, rock climbing, mountaineering, motor racing, etc. and get injured - the treatment costs won’t be covered by health insurance.
Administrative fees, registration fees, the cost of consumables such as hand gloves, masks, syringes, needles, etc. are some other expenses that are permanently excluded from health insurance.
Note- The above list is not exhaustive. You need to check the terms and conditions of the policy or speak to your financial advisor to know the exact exclusions applicable in your policy.
Additional Permanent Exclusions
Besides the standard permanent exclusions, we've mentioned above, insurance companies may apply additional exclusions for specific situations or medical conditions
Basically, if you're suffering from certain diseases or serious medical conditions that the insurers find risky to cover, they may permanently exclude them and then issue the policy to you.
However, it's important to note that insurers are restricted to a set of illnesses listed under regulation for which they can apply a permanent exclusion. Insurers cannot apply permanent exclusion to diseases outside this list.
For instance, Ajay, 25, has Hepatitis B and wants to apply for a health insurance policy. The insurer, however, is finding it risky to offer him coverage because of his medical history. So, they tell him that they would provide him health insurance coverage only on one condition - they will permanently exclude 'Hepatitis B'.
If Ajay agrees and buys the health plan- and later undergoes hospitalisation for a treatment that is related to Hepatitis B, the insurer won’t pay for the expenses.
Please note, there might be situations, beyond the ones we've covered in this article, that a health insurance policy won't cover. So, ensure you check the policy wordings before you go ahead and make the purchase.