Let us imagine Tarun and Shivani are working in the same organization. Tarun is hospitalized for a covid infection and Shivani decides to get a cosmetic procedure done. Tarun spends close to Rs.50,000 on his medical bills whereas, Shivani spends around Rs.75,000 on the procedure. After discharge, they decide to raise a health insurance claim as they have an active group health insurance policy.
For Tarun, the TPA approves the claim and he gets the money spent on the medical bills reimbursed. On the other hand, Shivani’s claim gets rejected. The health insurance TPA informs Shivani that cosmetic procedures are not covered in her insurance plan. Cosmetic procedures are mentioned as exclusions in the insurance policy hence, the claim is rejected.
Now, why did this happen?
Shivani was unaware of the exclusions mentioned in her GHI policy. As a result of which she had to pay it on her own.
So, this is why one has to read the policy wording of their insurance carefully before going for any treatments or procedures.
Exclusions in health insurance, what is it?
Always know that your health insurance plan will not cover every medical expense of yours and there are certain exclusions in the insurance policy. A health insurance plan, individual or group plan generally covers most diseases and treatments. However, there are certain treatments and medical conditions which are not covered by your plan. These are known as exclusions in a health insurance policy.
These are always clearly mentioned in your insurance contracts. So just like Shivani, you will have to pay the medical bills out of your pockets when you raise a claim for such exclusions.
However, in an individual health insurance plan, pre-existing diseases are covered after a certain waiting period. Hence, they are considered exclusions during the waiting period.
However, your group plan is different. It covers your pre-existing diseases from day 1 with 0 waiting period.
So, as long your group plan is considered, pre-existing diseases and waiting periods are not exclusions in your health insurance plan.
Common exclusions in your insurance policy
Some of the common exclusions in your group insurance policy are
Permanent exclusions in health insurance
Permanent exclusions in health insurance policies are those treatments and conditions which will be never covered in your plan at any point in time. They are permanently excluded from your health insurance. These include HIV, AIDS, congenital diseases, damages due to war or nuclear weapons, etc.
Cosmetic treatments or surgeries which enhance the appearance of people are generally not covered in your group insurance policy. However, plastic surgeries or reconstructive treatments due to accidents, burns or cancer may be covered in your policy depending on its terms and conditions.
Injuries due to self-harm
Treatment expenses generated due to injuries caused by suicide attempts or any other self-harm are not included in your policy.
Substance abuse/alcoholism treatments
Expenses related to treatments or procedures on the account of substance abuse, alcoholism or any other addiction are excluded from coverage.
Your group health insurance policy do not cover expenses generated due to alternative treatments like naturopathy, acupuncture, magnetic therapies or any such treatments.
Other exclusions in the health insurance policy
According to the IRDAI circular, there is a standard list of exclusions for your health insurance contracts. However, a few like pre-existing diseases and waiting periods do not apply to a group insurance policy.
Hence, other exclusions in your group policy will be
Dental treatments are considered cosmetic procedures by the insurer. Hence, expenses due to dental treatments are not covered in your policy. But dental treatments due to accidents or injury may be covered by your insurer. However, while purchasing your group plan you can add a rider plan to cover dental treatments.
Just like dental insurance, maternity-related hospitalization and other expenses towards it are not covered by default in your group policy. However, you can purchase maternity insurance as an add-on cover to your group health insurance plan.
Gender changing treatments
Expenses due to treatment or surgeries to change the gender of an individual are considered exclusions in your policy.
Hospital expenses limit
Most group health insurance policies provide you with room rent and ICU room expenses, doctor’s consultation expenses, and diagnostic tests expenses. However, there is a limit on these expenses for most plans, unless you go for an add-on cover. Read your policy wording carefully to know the conditions attached to them.
Mental illness treatment
Your group health insurance policy may not cover expenses that arise due to mental illness or disorders treatment.
Hospitalization without doctors’ recommendations
Any hospitalization expense without a doctors’ recommendation will not be covered in your group insurance plan unless it's an emergency hospitalization.
Miscellaneous expenses include the cost of hearing aids, spectacles, health supplements or any other items included in the IRDAI’s list of expenses excluded category will not be covered by your insurer.
How is your group health insurance experience better with Pazcare?
At Pazcare we are open with our policies. With that, we mean as an HR or an employee, you get to know what is covered and not covered in your group health insurance plan.
If you are an HR/ admin, access the inclusions and exclusions in your admin dashboard.
Log in →access benefits→health insurance
Employees can access the inclusions and exclusions in the employee dashboard.
Log in →access benefits→health insurance
Purchase your group health insurance policy after you read the terms and conditions of the policy. Every health insurer has its own set of inclusions and exclusions mentioned in its policy. However, the above-mentioned ones are common exclusions in any plan. Sometimes, you can pay a higher premium and get make some like materinity, OPD and dental exclusions as inclusions. This has to be done when your buy the policy as there won't be any changes to the policy after your buy it. If you have any doubts regarding the purchase of group insurance plans for your team, contact Pazcare’s customer support, and we are more than happy to help you out.
Hereafter, don’t be surprised by your medical bills, be aware of your insurance policy.