Waiting Period & Exclusions in Health Insurance

Health Insurance plan comes up with list of waiting periods & exclusions – it is important we understand what is NOT COVERED in the health insurance, than what is covered. 

These exclusions & waiting periods are almost common across all the companies in India.

Following are the generic 2 types of exclusions that any health insurance policy:

1) 2-year Exclusions / Waiting Periods: Certain diseases / Treatments are not covered for the first 2 years of taking up the policy. These are typically not life-threatening ones. Ex. Cataract, Piles, Hernia, Varicose veins, Sinusitis, ENT related, etc. The reason for not covering up these in the initial 2 years is because one should not opt for health insurance just only to take up treatment of these diseases, that is having this existing condition & hence taking up a policy for the treatment – “Insurance is always for the unforeseen & not for what is already present”. 

2)  Permanent Exclusions: These are not covered during the entire course of the policy. Ex. Cosmetic treatments, non-medical items during hospitalization like record keeping / registration charges, regular medical check-ups / diagnostic tests, vitamins, tonics, Pregnancy (in certain policies it is covered after few years), weight control, etc.

Apart from the above:

      3)   Pre-Existing diseases that are declared & accepted will not be covered for the first 2-4 years, based on the policy conditions. Non-disclosure of these will result in the claim getting rejected & policy cancelled too.

 4)   Certain policies, especially for senior citizens comes with Co-payment clause. This means the claim amount must be shared partially by the insured person depending on the percentage as specified. Ex. If the co-payment is 20% & the claim amount admitted after all non-payables is 1 lakh, then 20,000/- must be borne by the insured & 80,000/- will be paid by the health insurance company.

 5)   Deductible: This is an optional amount that would be deducted from the claim amount. The insured is given an option to choose the deductible amount, say 50,000/-. In this case, the claim amount totaling up to 50,000/- in a year will not be paid by the insurance company. If the total claim amount in the year exceeds 50,000/-, from then on, the claim amount is payable. If one chooses this option, then the premium payable will be less.

Health insurance must be taken when one is healthy or when he has insurance with his company, so that he lives through the initial waiting periods when he has coverage elsewhere. Waiting till the last minute to take up insurance may deny the possibility of getting the cover itself.