Medical insurance: Here is what your health cover does not pay for

When Mumbai-based Shweta Jaisingh (name changed) tried to buy a health insurance policy, her application was rejected. Jaisingh said, “I suffer from rheumatoid spondylitis. The severity of my condition is 1/10, which means it is almost non-existent. I declared it while applying for the policy in good faith.”

She was ready to for a higher premium or longer waiting period, but was not given any such option. “The issue is that rheumatism as a category is excluded from health insurance,’’ she added.

It is probably cases like this, which has forced Insurance Regulatory and Development Authority of India (Irdai) to start the exercise to minimise the number of exclusions, that is illness and diseases which are not covered under health insurance policies. But whether the committee will provide relief to patients like Jaisingh is yet to be seen.

According to a senior official from a general insurance company, the committee’s role is to not get into what insurance companies should and should not cover, but to address the ambiguous wordings insurers use.
“Today, the regulator does it on a case-to-case basis when products are filed. But there should be framework for such exclusions,’’ he said.

While the types of insurance policies have risen, exclusions too, have increased. With tough-to-understand medical terms being used for exclusions, policyholders often discover only at the claim stage that the insurer will not cover these expenses. With the hospital already having billed those so-called ‘non-billable’ expenses, there is no other way but to pay the money from one’s own pocket. DNA Money tells you about other dreaded exclusions like rheumatism.

Commonly excluded conditions and diseases

To begin with pre-existing diseases are covered by most medical insurance policies, only after 24-48 months of continuous coverage. If you fall sick due to such ailments before the time limit, you have to foot the bill on your own.

Many insurance policies do not pay for any disease contracted during the first 30 days, from the commencement date of the policy. But even if you fall sick after the ‘cooling off’ period, there is no guarantee that all your expenses will be reimbursed. There is a long list of exclusions of diseases that can happen to almost anybody and customers cannot be blamed for believing that insurance policies are designed to avoid paying claims.

Insurers do not cover the cost of spectacles and contact lens, hearing aids, walkers, dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalisation.

A senior citizen health insurance policy has exclusions like cataract, ENT related diseases, hernia, and pancreatic diseases, etc, which mostly occur after 60 years.

Some diseases and ailments that occur due to hereditary or genetic reasons are not covered. Many insurers do not pay for treatment of degenerative disc of vertebral diseases, varicose veins and ulcers, sinusitis, and fistula, among others.

All treatments, for hepatobilary gall bladder, pancreatic stones and genito-urinary calculi are also excluded. Dysfunctional uterine bleeding, pelvic inflammatory diseases, all diseases of fallopian tubes and ovaries, etc, are also excluded by some insurers.

Insurers also use terms like convalescence, general debility, nutritional deficiency states, psychiatric, psychosomatic disorders, etc for exclusions.

Hospitalisation cost for ‘evaluation and diagnostic purposes’ are a strict no-no, even if required.

Hard to understand terms

Currently, since exclusions are highly technical and non-uniform, a normal customer’s ability to understand the boundaries of what is excluded and what is included is limited. This could lead to claim rejection.

“There is no standard definition of exclusions like ENT diseases, motor neurone diseases, etc. Standardising and minimising exclusions will streamline the whole process,” said Vaidyanathan Ramani, head product and innovation, Policybazaar.com.

Reason for exclusions

According to Vikas Mathur, head - health, Universal Sompo General Insurance said exclusions help keep premiums fair by eliminating the possibility for unusual high risk events.

“Conditions like diabetes mellitus, hypertension, etc, pre-existing to the policy are covered after three to four years. Few listed surgeries are covered after waiting periods of one to two years,” he said.

Permanent exclusions

Some HIV, congenital external diseases, etc, are usually permanently excluded. Dental surgeries other than due to accidents, cosmetic/aesthetic surgeries, etc, are also excluded.

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Ashish Mehrotra, MD & CEO, Max Bupa Health Insurance, said: “Irdai’s latest initiative to reduce health insurance policy exclusions and standardise the nomenclature will bring more people under the gamut of health insurance coverage.”

Source: DNA Money