Permanent Exclusions In Health Insurance

Manav loves to party, and his lifestyle includes regular smoking and drinking alcohol. One night after a party, he suddenly falls unconscious and is taken to the hospital.

Manav is not at all worried about the expenses as he is covered under health insurance. He is discharged the next day after the treatment is done. The hospital bill amounts to Rs. 75,000. At the time of making the payment, Manav finds out that the insurer won’t cover his hospitalisation expenses. Treatment for illnesses or injuries because of excessive intake of drugs, alcohol, smoking, etc. are not covered under his policy.

This came as a shock to Manav, and he had to pay the entire hospital bill out of his pocket. In order to ensure there are no such surprises at the time of a health insurance claim, it is extremely crucial to educate yourself about everything that is covered by your health insurance policy - and, more importantly, everything that isn't.

In this article, we discuss several permanent exclusions under health insurance - situations that your health insurance will never cover. But before we get into that, let us first understand what permanent exclusions mean.

What Are Permanent Exclusions?

Permanent exclusions are situations or conditions that are out of scope of coverage of the policy and hence will never be covered under health insurance. So, if you apply for a claim for such a condition or a treatment, the insurer will not pay the claim.

For instance, Elena buys a health insurance policy for a sum insured of Rs. 5 Lakhs. There is a list of permanent exclusions in the policy document, where one of the exclusions mentioned is 'maternity costs'. This means that any maternity-related expenses incurred by Elena during the policy term will not be covered by her health insurance plan.

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Types Of Permanent Exclusions

There are 2 types of permanent exclusions in health insurance -

Standard permanent exclusions

Additional permanent exclusions

Let's learn about both these types in detail.

  • Standard Permanent Exclusions

    Every insurance company has a list of standard exclusions that they will never cover. Here are a few examples of standard permanent exclusions -

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.

Maternity Costs

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.

Outpatient Expenses

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.

Unproven Treatments

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.

Other Costs

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.

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That is all about permanent exclusions under health insurance. As important as it is to understand the costs that your health insurance will cover, it is equally important to be aware of all situations/ conditions that it won’t cover. So, before you go ahead and buy health insurance for yourself and your loved ones, ensure you make yourself aware of all the exclusions - so that you’re not taken by surprise at the time of a claim.

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