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Every health insurance plan comes with certain exclusions. These diseases are not covered under the health insurance policy. The exact list of diseases will vary from one health insurance provider to another, and also from one policy to the next. However, broadly speaking, some diseases and medical conditions that are not commonly covered by health insurance include HIV/AIDS, sexually transmitted diseases, genetic conditions, infertility and dental treatments. Read this article to learn more about the common exclusions during the waiting period of a health insurance plan and the exclusions specified by the IRDAI.

Important Update (Dated May 30, 2024) – Good news for Health Insurance policyholders! According to the Master Circular on Health Insurance Business 29052024 rolled out on May 29, 2024 by IRDAI, insurers are to decide on the request for cashless claims within 1 hour of receiving the request. Also, the final claim is to be granted within 3 hours after the policyholder’s discharge from the hospital. Insurers have been directed by IRDAI to establish necessary systems and procedures for this process by July 31, 2024.

 

The Master Circular on Health Insurance Business 29052024 circular is available here - https://irdai.gov.in/document-detail?documentId=4942918

Having good health insurance for yourself and your family members is extremely crucial as the cost of healthcare in India has jumped exponentially over the past few years. The COVID-19 pandemic has also proven to be an example of why people should mandatorily have health insurance. Even minor treatments or hospitalisations at reputed private hospitals can cost lakhs of rupees if you are not medically insured. However, you should also consider health insurance exclusions and diseases that are not covered before buying a policy.

 

Some diseases and conditions that may not be covered by your health insurance includes -

 

  1. HIV/Aids and other sexually transmitted diseases

  2. Infertility

  3. Injuries/illnesses that result from illegal activities

  4. Injuries suffered as a result of engaging in adventure sports

  5. Addiction treatments

  6. Dental treatments (unless the dental injury results from an accident)

  7. Genetic Disease/Congenital conditions

Disclaimer: All insurance plans have their own separate list of exclusions, so some of the above diseases may very well be covered in certain plans but excluded in others.

Disease Not Covered Under Waiting Period

Although most health insurance plans cover a wide majority of diseases,  there are certain illnesses that are not covered for the first few years. Given below is the list of diseases not covered under health insurance but come with a waiting period -

 

  1. Gastrointestinal Ulcers

  2. Any forms of fistula

  3. Benign Prostatic hypertrophy

  4. Any types of sinuses

  5. Haemorrhoids and Piles

  6. Dysfunctional Uterine bleeding

  7. Endometriosis

  8. Pancreatitis

  9. Cataracts

  10. Macular Degeneration

  11. Hernia

  12. Fibromyoma

  13. Hysterectomy

  14. Cirrhosis

  15. Tonsillitis

  16. Mental illnesses like Alzheimer’s and Dementia

What are Health Insurance Exclusions?

The Insurance Regulatory and Development Authority of India (IRDAI) has a list of diseases/medical that are not covered under health insurance:

  • Cosmetic Surgeries

Any expense related to cosmetic surgery is not covered in the policy. These include Liposuction, Botox, or any similar kind of surgery. This is unless a doctor prescribes any plastic surgeries or hair transplants following a grave incident such as deformation caused in an accident or due to critical health conditions.

  • IVF and Fertility Treatment

Most general health insurance providers also do not offer coverage for IVF procedures or fertility treatments.

  • Pregnancy and Abortion

Many health insurance plans in India do not cover medical expenses arising due to pregnancy and abortion.

  • Miscellaneous Charges

Other charges such as registration charges, admission fees, and service charges related to medical treatment are not covered under certain health insurance plans.

  • Health Supplements

Health supplement costs and protein shake expenses are not covered under health insurance in India. One has to pay these from their pocket.

  • Alternative Therapies

Usually, health insurance plans do not cover Ayurvedic and Homoeopathic treatments. Treatments such as naturopathy, acupuncture, magnetic therapy, acupressure, etc. are not covered under the policy. Check for health insurance at Bajaj Markets as the policy covers Ayurvedic and Homoeopathic treatments under it.

  • Pre-Existing Health Conditions

Pre-existing diseases are not covered under health insurance right away. Certain plans do not provide cover for high blood pressure and diabetes, while many others do. The insurer will provide a waiting period after which the claims for the pre-existing health conditions can be made. The waiting period depends on the insurer and can be between 12-48 months.

  • Self Harm

Health insurance also does not cover any injuries or medical issues arising from a person causing themselves harm.

Waiting Periods vs Exclusions

Many people who look into buying health insurance may become confused between the ‘waiting period’ and ‘exclusions’. Let us understand both of these terms briefly.

In terms of health insurance, a ‘waiting period’ refers to a time frame of a few months or years where the health insurance provider does not provide coverage for pre-existing conditions. For e.g., if an individual has diabetes as a pre-existing condition and applies for health insurance, the health insurance policy will typically have a waiting period of a few months or years where treatment for diabetes will not be covered. However, once the waiting period is over, the insurer will start providing coverage for diabetes.

 

On the other hand, exclusions are certain diseases or medical conditions that are not covered by the health insurer at all, under any conditions. When you look at exclusions in a health insurance plan, these are medical issues that the insurance will not cover throughout the full term of the policy.

 

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To Conclude

You must understand the health insurance coverage and exclusions correctly before buying the policy. That way, you will be able to make a successful claim on your health insurance plan. Other things that you can consider when buying health insurance are the premiums charged, coverage of the plan, claim settlement ratio of the insurer, etc. Based on the evaluation, you can then choose a health insurance policy from Bajaj Markets that best suits your needs.

Best Health Insurance Plans Available on Bajaj Markets

FAQs on List of Diseases Not Covered Under Health Insurance

What are the pre-existing conditions that are not covered by health insurance?

Some common pre-existing conditions not covered by health insurance are:

  1. Diabetes

  2. Cancer

  3. Asthma

Can I buy extra cover for diseases that are not covered by health insurance?

Many health insurance providers offer customised add-ons that you can buy for specific medical conditions or for additional coverage. 

What is the waiting period for diabetes in health insurance?

Every health insurance provider has its own set of rules regarding ‘waiting periods’ so you should read the policy before buying. 

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