What is and isn’t covered in your health insurance policy

25 May 2019

No matter how young or old we are, how health conscious we are or aren’t; health risks can creep up any time. We may require sudden hospitalisation which brings with it a lot of emotional and financial stress. Instead of worrying about how finances can be managed in such stressful times, it is better to plan in advance and invest in a good, all-encompassing, health insurance policy that offers coverage against a host of conditions and diseases. Also, it is important to read the terms and conditions to understand what your insurance policy entails along with the list of diseases not covered under health insurance. Here’s all you need to know about what is and isn’t covered under your health insurance plan.

What is covered by health insurance?

Your health insurance policy typically covers you for medical expenses incurred as a result of the diagnosis of a diseases or a health condition. Generally, there is no specific list of diseases covered under medi-claim as most illnesses including heart diseases cancers, tumours, sudden heart attacks, bypass surgeries etc. are covered under your health insurance policy. Apart from medical expenses you are also entitled to:

What does long term health insurance cover?

Long term health policies typically cover the cost of hospitalisation in case one needs to be hospitalised for a longer duration. It also helps reduce costs associated with living in an assisted living or home assistance facility due to a prolonged illness. Such a policy typically comes to your aid when you have no one to look after you or take care of you, while you are also not in a position to look after yourself physically.

• Pre and post hospitalisation expenses:
  Doctors ask for medical reports before and after treatment. The costs of these are covered in the health policy, for a period of up to 60 days before treatment begins and 90 days after surgery.
• Cashless admission facility:
  Insurance companies generally issue identity cards to policy holders which allow the latter to seek admission in any of the hospitals falling under the insurance providers network without having to make any advance payments.
• Reimbursement for medical expenses:
  In case your preferred hospital is not among the network hospitals, you can seek treatment there and submit your claim for reimbursement by providing all original bills and documents as listed in the health policy.
• Hospitalisation cash benefits:
  In case one is diagnosed with an illness that requires him/her to be hospitalised for a longer duration of time, the policy also covers everyday hospitalisation, typically up-to a period of 50 days.
• Pre-existing conditions:
  While your health insurance doesn’t cover you for most pre-existing conditions, there are some insurance providers who offer specific policies for pre-existing medical conditions such as diabetes, asthma etc. That said, the policy holder has to honour the pre-decided waiting period, typically three to four years before he/she can file a claim.
• Ambulance charges:
  Some insurance providers also provide coverage for ambulance charges, which generally cost a few thousands.

Diseases not covered under medi-claim policy

As mentioned above, there is no particular list of diseases not covered under health insurance. However, there are certain things for which you cannot claim medical insurance. These include

• Conditions related to one’s lifestyle:

  Health plans generally exclude the coverage of treatment of diseases that are related to the lifestyle of the policy holder. These include lung diseases or lung cancers resulting from smoking or liver diseases like cirrhosis caused due to excessive consumption of alcohol.

• Alternative treatment:

  Most insurance policies only cover you for in-patient or allopathic treatments. You cannot claim coverage if you opt for alternative methods of treatment like Ayurveda, Unani, Naturopathy, acupressure, acupuncture, magnetic therapy and other such treatments.

• Pre-existing medical conditions:

  This is a point that is included in disease covered in health insurance as well as those that are not. To get coverage for pre-existing conditions, you need to truthfully mention them when you apply for medical insurance and cannot encash the policy until the pre-determined waiting period ends.

• Cosmetic treatments:

  While you become eligible for medically recommended plastic surgery procedures to treat injuries resulting for injuries or accidents, recreational cosmetic treatments such as plastic surgeries, nose jobs, face lifts, Botox and cosmetic implants are not covered.

• Reproductive challenges, pregnancy and child birth:

  Your health insurance also does not cover treatments related to reproductive challenges such as fertility challenges, in-vitro fertilisation, abortion and surrogacy. Most basic polices also do not cover you for pregnancy and child birth related expenses.

• Aids:

  Almost insurance providers include Aids in the list of diseases not covered under health insurance.

• Injuries caused as a result of suicide attempts:

  If one is hospitalised as a result of attempted suicide, they cannot encash their health insurance policy to seek coverage. Whenever you purchase and even renew your health insurance policy, it is best to read the terms and conditions to understand what is and isn’t covered in the policy. This way there will be no confusion when you wish to file a claim.

Why and when should I buy long term health insurance?

That the cost of medical expenses is increasing with every passing year is no hidden secret. In the last few years, it has been reported that the cost of health-care has been on an upward trajectory with a 15% inflation rate, annually. As such, it is best to invest in a long-term health care policy as soon as possible.

While you can continue paying premiums for your regular health insurance policies until the age of 50, the moment you reach this mile-stone, you should start investing in long-term insurance policies, because your 60s are a time when chronic illnesses begin to crop-up out of nowhere. Also, most insurance companies do not prefer to provide long-term health insurance policies when one enters their retirement years. This is attributed to the fact that senior citizens are generally considered as high risk customers since their health is more likely to start deteriorating once they enter their 60s.

Reasons to consider a long-term health insurance policy

Now that you know What Is Covered By Health Insurance, let’s look at the essential reasons why you should consider investing in this type of policy.

• One of the most common reasons why people prefer to invest in long-term insurance is that you do not have to go through the hassle of renewing your policy every single year, nor do you have to worry about your policy lapsing or losing out on the no-claims bonus.
• Since long term health insurance policies comes with a longer validity, the policy holder is also likely to gain the benefit of discounted premiums as compared to when one purchases a policy with a 1 year validity.
• Also, locking in your insurance plan for a period of 3 years makes the policy holder immune to premium rate revisions that may happen during this period. As mentioned above, with the annual inflation associated with the health care industry, most health insurance providers are increasing premium rates with every passing year.

Final Words

The IRDAI has also issued a regulation that makes insurance companies provide the No-claims bonus benefit to long term health insurance policy holders as well. The no-claims bonus slabs are fixed by the IRDAI and the policy holder can receive these benefits in the guise of claim-related concessions. For instance, insurance companies may offer bonuses for every claim-free year even in the case of policies lasting for three years.