List of Common Exclusions Under Health Insurance Policy

Exclusions in health insurance are conditions or treatments not covered, such as pre-existing diseases, pregnancy, self-inflicted injuries, cosmetic procedures, and adventure sports. Insurers set exclusions to manage risk and keep policies affordable.
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3 min
21-April-2025

Health insurance is a critical component of financial planning, providing a safety net against the rising costs of medical care. However, policyholders need to be aware of the terms and conditions of their health insurance policy, particularly the exclusions. Exclusions are specific conditions or situations that are not covered by the insurance policy.

Understanding these exclusions is crucial to avoiding unpleasant surprises and ensuring that your health insurance coverage aligns with your healthcare needs. In this article, we will explore why checking exclusions is important and highlight ten common exclusions found in health insurance policies.

Pro Tip

A comprehensive health plan not only covers hospitalization but also pre & post-treatment expenses, ensuring complete financial protection against rising medical costs.

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Why should you check exclusions before buying health insurance?

Before purchasing health insurance, it is imperative to carefully review the policy document and understand the exclusions. Failing to do so may lead to misunderstandings and financial setbacks when making a claim. Here are some key reasons why checking exclusions is crucial:

  • Clarity on coverage:
    Reviewing exclusions helps you gain clarity on what is covered and what is not under your health insurance policy. This knowledge allows you to make informed decisions about your healthcare and financial planning.
  • Financial preparedness:
    Knowing the exclusions helps you financially prepare for potential expenses that may not be covered by your health insurance. This ensures that you are not caught off guard during a medical emergency or planned medical procedures.
  • Avoiding disputes:
    Understanding exclusions prevents disputes with the insurance company during the claims process. Being aware of the limitations of your policy can help you navigate the claims process smoothly and reduce the chances of claim rejection.
  • Choosing the right policy:
    Different health insurance policies have varying exclusions. By carefully examining the exclusions, you can choose a policy that aligns with your health needs and preferences.
  • Managing expectations:
    Knowing the exclusions sets realistic expectations regarding your health insurance coverage. It prevents assumptions that may lead to disappointment when specific healthcare expenses are not covered.

What are the common exclusions of health insurance

  • Pre-existing conditions:
    Most health insurance policies have exclusions for pre-existing conditions. A pre-existing condition refers to any medical condition that you had before purchasing the policy. You can get an add-on for pre-existing disease cover.
  • Waiting Period Clause
    Every policy includes a waiting period for specific treatments or diseases—usually 30 days for general illness and up to 2–4 years for major surgeries or pre-existing conditions.
  • Non-Medical Expenses
    Items like gloves, masks, oxygen masks, registration charges, and administrative costs are usually not covered under standard policies. Always check the list of non-payables in your policy.
  • OPD Treatments
    Outpatient treatments, including routine doctor visits, dental care, and minor procedures not requiring hospitalization, are generally excluded unless specifically covered in your plan.
  • Obesity Treatments
    Weight loss surgeries or treatments related to obesity, unless prescribed due to life-threatening complications, are often excluded as they’re considered lifestyle-related.
  • Sexually Transmitted Diseases (STDs)
    Conditions like HIV/AIDS or other STDs are typically excluded due to their long-term treatment needs and non-curative nature, unless mentioned in a critical illness policy.
  • Dietary Supplements
    Health tonics, protein powders, or vitamins not prescribed by a doctor as part of a treatment plan are usually excluded as they are considered general wellness items.
  • War & Related Perils
    Medical issues arising from war, terrorism, civil unrest, or nuclear activity are not covered as they fall under high-risk exclusions outside the insurer’s control.
  • Assisted Reproductive Technology (ART)
    Treatments like IVF, IUI, and other infertility-related procedures are excluded unless the policy explicitly covers them as part of maternity or fertility benefits.
  • Hazardous or Adventure Sports
    Injuries from activities like skydiving, rock climbing, or bungee jumping are excluded since they involve intentional risk and are not medically necessary.
  • Congenital Disorders
    Birth defects or congenital anomalies present since birth are not covered unless the insurer offers a specific rider or plan extension for such conditions.
  • Cosmetic surgery:
    A health insurance policy may not cover cosmetic procedures such as facelifts, rhinoplasties, or liposuction, as they are typically voluntary and not necessary for medical reasons.
  • Dental care:
    Standard health insurance policies often do not cover dental care, such as fillings, crowns, root canals, and dentures. However, most insurers provide separate dental insurance policies that focus on dental care.
  • Experimental procedures:
    Health insurance policies usually do not cover experimental procedures such as stem cell therapy, which is still in the trial phase.
  • Alternative medicine:
    Alternative therapies like acupuncture, homoeopathy, and naturopathy are typically not covered by health insurance policies.
  • Maternity care:
    Some health insurance policies may not cover maternity care, including prenatal, delivery, and postnatal care.
  • Weight-loss surgery:
    Most health insurance policies have exclusions for weight loss procedures, such as gastric bypass surgery, which are primarily performed for cosmetic purposes.
  • Self-inflicted injuries:
    Suicide attempts, self-harm, or intentionally putting oneself in harm's way, such as consuming toxic substances or drugs usually are not covered in a health insurance policy.
  • Pregnancy and fertility:
    Many health insurance policies exclude infertility treatments, including in-vitro fertilisation, as well as procedures related to pregnancy such as childbirth and abortion.
  • Medical treatment overseas:
    Health insurance policies may have exclusions for medical care outside the country, even in case of an emergency medical evacuation.

How to check the exclusions in your health insurance policy?

To avoid surprises during claims, carefully review the exclusion in health insurance policies by:

  • Reading the policy wordings and fine print for listed exclusions.
  • Asking the insurer or agent for a detailed exclusions list.
  • Checking waiting periods and specific disease clauses.
  • Reviewing the IRDAI-mandated standard exclusions.
  • Comparing exclusions across plans before buying.

Ways to minimize the impact of health insurance exclusions

While exclusion in health insurance can’t be completely avoided, you can reduce its impact by:

  • Choosing add-on covers for pre-existing diseases or maternity.
  • Opting for comprehensive plans with minimal exclusions.
  • Starting early to reduce waiting periods.
  • Keeping detailed medical records to avoid claim disputes.

Conclusion

When buying a health insurance policy, it is essential to understand the policy's exclusions to ensure that you are not caught off guard when making a claim. By knowing the common exclusions in health insurance policies, individuals can make informed decisions and choose policies that offer the necessary coverage. Before purchasing a health insurance policy, it's crucial to compare various insurance plans to ensure that you receive the best value for your money. Ultimately, it is essential to read the policy document carefully, understand all the terms and conditions, and ask questions to clarify any doubts.

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Frequently asked questions

What are the exclusions of health insurance policy?

Exclusions in a health insurance policy refer to specific medical conditions, treatments, or scenarios that the insurer will not cover. These typically include pre-existing diseases (within a waiting period), cosmetic surgeries, injuries due to hazardous sports, self-inflicted harm, and illnesses caused by substance abuse. Understanding exclusions helps prevent claim rejections later.

What is not covered in a health insurance policy?

Health insurance policies do not cover non-medical expenses like hospital registration fees, dietary supplements, or over-the-counter vitamins. Treatments for HIV/AIDS, infertility, congenital anomalies, and OPD consultations are also commonly excluded unless your plan specifically includes them. Always check the policy brochure to know what's not covered.

What are typical exclusions in an insurance policy?

Typical exclusions in an insurance policy include pre-existing conditions (for a certain period), STDs, cosmetic or weight-loss surgeries, and any health issues arising from war, riots, or participation in dangerous activities. These exclusions help insurers manage high-risk scenarios and are usually detailed in the policy’s terms and conditions.

What are the 2 year exclusions?

Two-year exclusions refer to specific diseases or treatments that are not covered for the first 24 months of the policy. These commonly include hernia, cataracts, joint replacements, and certain surgeries. After completing the waiting period without any claim, coverage for these treatments is typically activated.

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