What Your Health Insurance Policy Will Not Cover

Illnesses as a result of substance abuse: If it is evident that your illness is a result of excessive smoking, alcohol consumption and other illicit substances, your claim will be rejected.

Treatment at home: If the patient is not hospitalized, the claim will be void. Although, some policy providers may cover treatment at home, the amount that can be claimed will be less.

Certain Drugs and medications: Not all Drugs used to treat critical illnesses like cancer are covered by the insurers. Some chemotherapy drugs which are taken orally are not covered, drugs falling under immunotherapy are generally not covered too. Some policies do not cover the injections administered intra-artery and intra-lesionally.

Resident doctor’s charges: If the resident doctor’s charges are mentioned separately in the bill, it will not be covered. However, if it is included in the room charges, it may be covered depending on the policy provider.

New or Advanced treatments: Unproven or experimental treatments like robotic surgery are not a part of policy coverage. Stem cell therapies are also usually not covered.

Non-medical expenses: Expenses related to Toiletries and other convenience items are excluded from policy coverage. For the list of all items excluded from coverage, you can refer the circular no. IRDA/HLT/CIR/036/02/2013 released by IRDAI.

Pre-existing illnesses: Usually pre existing illnesses are either not covered at all, or not eligible for claim until a certain lock-in period decided by the insurance company.

Types Of  Health Insurance

When you choose a health insurance policy, your medical expenses will be taken care of by your policy provider and in return, you are required to pay an annual fee, called ‘premium’ which can also be paid in monthly instalments. Depending on which policy you opt for and who provides it, health insurance protects your wallet by covering treatment expenses, Hospitalization charges, ambulance costs, laboratory costs and other related expenses. Some policies even cover compensation for lost income.

Types Of Health Insurance

Indemnity Plan: Until about three decades ago, indemnity plan was the popular type of health insurance. In this case, a certain amount of the hospital expenses is to be paid by you, and the insurance provider will take care of the rest of the bill. 

You can choose which doctor to visit and the insurance company does not get to decide the hospital or verify whether the visit was necessary. But this autonomy is only to a certain extent. Clearance from the insurance company is still required in case of emergencies, for admission into an emergency room if you are not incapacitated. If you choose Indemnity plan, you will have to pay the whole bill out of your pocket first then claim for a reimbursement.

Health Savings Account: It is a type of Savings account where you contribute some amount, up to a certain limit which is tax free. Unused funds roll over each year and the interest gained is also tax free. It is a good option to those who cannot afford a group health insurance policy and those who are more inclined to tax free health plans.

Exclusive Provider Organization (EPO): Members of an EPO plan will be required to use a defined network of physicians and a Primary Care Physician (PCP) who will provide referrals to network specialists for treatments. However, this condition is not applicable for emergencies. You will be responsible for a small amount of co-payment too.

Point of Service (POS): Just like in EPO pan, POS also provides a PCP to choose from the network providers. In such cases, you will receive higher coverage. However, if you choose a non-network hospital, you may be subject to a deductible (co-payment) and coverage will be less too. Also, you may have to pay up front and then claim a reimbursement.

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