What is not covered in your health insurance policy?

What is not covered in your health insurance policy is a bigger list than what is covered in your health insurance policy. There are first-year exclusions, second-year exclusions, third-year exclusions, Pre-Existing Diseases (PED), specific diseases and procedures, etc

It is not possible for the advisors to know each and every year’s exclusions.  Better get a copy of the exclusions before proposing the health insurance policy. 

The list of exclusions has been collected from the STAR HEALTH INSURANCE COMPANY. The terms and conditions, including exclusions, may change from the company to company. Please collect all the information before signing the health insurance policy. 

BASIC EXCLUSION:

30-day waiting period

A. Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded, except claims arising due to an accident, provided the same are covered

B. This exclusion shall not, however, apply if the Insured Person has had continuous coverage for more than twelve months

C. The within-referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently

STANDARD EXCLUSIONS

A. The Company shall not be liable to make any payments under this policy in respect of any expenses whatsoever incurred by the insured person in connection with or in respect of

Pre-Existing Diseases 

A. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer

B. In case of enhancement of sum insured, the exclusion shall apply afresh to the
extent of sum insured increase

C. If the Insured Person is continuously covered without any break as defined under the portability norms of the existing IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage

D. Coverage under the policy after the expiry of 36 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by Insurer

 

Specified disease / procedure waiting period 

A. Expenses related to the treatment of the following listed conditions, surgeries, or treatments shall be excluded until the expiration of 24 months of continuous coverage after the date of the first policy with the company. This exclusion shall not be applicable for claims arising due to an accident

B. In case of enhancement of sum insured, the exclusion shall apply afresh to the extent of sum insured increase

C. If any of the specified diseases or procedures fall under the waiting period specified
for pre-existing diseases, then the longer of the two waiting periods shall apply

D. The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion

E. If the Insured Person is continuously covered without any break as defined under
the applicable norms on portability stipulated by IRDAI, then waiting period for
the same would be reduced to the extent of prior coverage   

List of specific diseases/procedures;

i. Treatment of Cataract and diseases of the anterior and posterior chamber of the eye; Diseases of ENT; Diseases related to the Benign diseases of the breast

ii. Subcutaneous Benign Lumps, Sebaceous cyst, Dermoid cyst, Mucous cyst lip / cheek, Carpal Tunnel Syndrome, Trigger Finger, Lipoma, Neurofibroma, Fibroadenoma, Ganglion and similar pathology

iii. All treatments (Conservative, Operative treatment) and all types of intervention for Diseases related to Tendon, Ligament, Fascia, Bones and joints, Including arthroscopic and arthroscopic / Joint Replacement (other than those caused by accident)

iv. All types of treatment for Degenerative disc and Vertebral diseases, including Replacement of bones and joints, degenerative diseases of the Musculo-skeletal system, and prolapse of the intervertebral disc (other than those caused by accident)

v. All treatments (conservative, interventional, laparoscopic, and open) related to hepato-pancreato-biliary diseases, including gall bladder and pancreatic calculi. All types of management for Kidney and Genitourinary tract calculi

vi. All types of Hernia

vii. Desmoid Tumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula

viii. All treatments (conservative, interventional, laparoscopic and open) related to all Diseases of Cervix, Uterus, Fallopian tubes, Ovaries, Uterine Bleeding, and Inflammatory Diseases

ix. All Diseases of Prostate, Stricture of the Urethra, and All Obstructive Uropathies

x. Benign tumors of Epididymis, Spermatocele, Varicocele, and hydrocele

xi. Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal Prolapse, Stress Incontinence

xii. Varicose veins and Varicose ulcers

xiii. All types of transplant and related surgeries (Other than Bone Marrow Transplant for acute hematological malignancies and acute medical emergencies when indicated)

xiv. Congenital Internal disease / defect

E. List of specific diseases/procedures;

i. Treatment of Cataract and diseases of the anterior and posterior chamber of the eye; Diseases of ENT; Diseases related to the thyroid; benign diseases of the breast

ii. Subcutaneous Benign Lumps, Sebaceous cyst, Dermoid cyst, Mucous cyst lip / cheek, Carpal Tunnel Syndrome, Trigger Finger, Lipoma, Neurofibroma, Fibroadenoma, Ganglion and similar pathology

iii. All treatments (Conservative, Operative treatment) and all types of intervention for Diseases related to Tendon, Ligament, Fascia, Bones and joints, Including arthroscopic and arthroscopic / Joint Replacement (other than those caused by accident)

iv. All types of treatment for Degenerative disc and Vertebral diseases, including Replacement of bones and joints, degenerative diseases of the Musculo-skeletal system, and prolapse of the intervertebral disc (other than those caused by accident)

v. All treatments (conservative, interventional, laparoscopic, and open) related to hepato-pancreato-biliary diseases, including gall bladder and pancreatic calculi. All types of management for Kidney and Genitourinary tract calculi

vi. All types of Hernia

vii. Desmoid Tumor, Umbilical Granuloma, Umbilical Sinus, Umbilical Fistula,

viii. All treatments (conservative, interventional, laparoscopic and open) related to all Diseases of Cervix, Uterus, Fallopian tubes, Ovaries, Uterine Bleeding, and Inflammatory Diseases

ix. All Diseases of Prostate, Stricture of the Urethra, all Obstructive Uropathies,

x. Benign tumors of Epididymis, Spermatocele, Varicocele, Hydrocele,

xi. Fistula, Fissure in Ano, Hemorrhoids, Pilonidal Sinus and Fistula, Rectal Prolapse, Stress Incontinence

xii. Varicose veins and Varicose ulcers

xiii. All types of transplant and related surgeries (Other than Bone Marrow Transplant for acute hematological malignancies and acute medical emergencies when indicated)

xiv. Congenital Internal disease / defect

 

At the end:

Insurance is a vast topic. No one knows fully.  Before buying an insurance policy, ask for the brochures and read them carefully. As an advisor, I had to fight many times. As a proposer or a customer, please reveal all information pertaining to pre-existing disease (PED), surgeries, illness, etc Never buy online insurance; always buy insurance coverage products from an experienced advisor who can help you as well as your nominees. 

We always try to provide cashless treatment to our policyholders. If the health insurance company found a problem in the opinion of the treating doctor, then only they would ask to go for reimbursement. 

To buy the best health insurance plan, call 9972660645