Health Insurance Exclusion List Updated from IRDAI

Permanent exclusions in health insurance are restrictions on coverage of certain illnesses, treatments, procedures, and services. Each health plan has its own set of exclusions, meaning that not all plans cover the same things. For example, some plans may not cover pre-existing conditions, while others may not cover certain prescription drugs or alternative treatments. Exclusions can vary widely between plans, so it is important to understand what is and isn’t covered when shopping for a health plan.

The Insurance Regulatory and Development Authority of India (IRDAI) has recently updated its list of exclusions, or the conditions, which won’t be covered by a regular health insurance plan.

Health Insurance Exclusions

It is important to understand the exclusions of any health plan before enrolling. Knowing what is and isn’t covered can help you make an informed decision and avoid unexpected costs. Here is a list of permanent exclusions in health insurance as per IRDAI.

1. Investigation and Evaluation:

The first in the updated health insurance exclusion list is any expense regarding diagnosis solely for the purpose of evaluation. However, if you are undergoing medical treatment in a hospital, such costs will be covered.

2. Rest, Cure, Rehabilitation and Respite Care:

The IRDAI has excluded expenses for prolonged bed rest, like custodial care at home or nursing facility for personal care along with services for terminally ill individuals, which cater to their physical, social, emotional, and spiritual requirements.

3. Obesity and Weight Control:

If you undergo surgical treatment for obesity, without the advice of a doctor, then such medical expenditure will be excluded from health insurance coverage. Other conditions to be followed include the policyholder having a Body Mass Index (BMI) of 40 or more, being more than 18-years of age and a clinical-protocol supported surgery. If a policyholder has a BMI index of 35, along with comorbidities, like coronary heart disease, severe sleep apnea, uncontrolled Type-2 diabetes and obesity-related disease of heart muscle (cardiomyopathy), then coverage would be provided. But such coverage will be provided only after less invasive methods of weight loss have failed.

4. Gender Change Treatment:

Surgical treatment for change of gender is excluded from coverage

5. Cosmetic and Plastic Surgery:

Unless cosmetic/plastic surgery is required as part of medical treatment following an accident, burns etc., it will be excluded from health insurance coverage. A certified medical practitioner has to provide a certificate stating such a procedure is a medical necessity.

6. Hazardous or Adventure Sports:

If you suffer from injuries due to participation in hazardous or adventure sports, like rock-climbing, motor racing, scuba diving and so on, then the cost of availing medical treatment will be excluded from coverage.

7. Breach of Law:

If you require medical treatment, while attempting to violate the law with a criminal intent, then coverage won’t be provided. 

8. Refractive Error:

Medical expenditure for correction of eyesight because of a refractive error less than 7.5 diotropes won’t be covered.

9. Excluded Providers:

The IRDAI has provided a list of excluded hospitals and medical practitioners on its website. New inclusions, if any, are notified to policyholders. If you avail treatment from them, coverage won’t be provided. In case of life-threatening situations, however, expenses up to the stage of stabilization can be claimed.

10. Treatment for Alcoholism, Drug or Substance Abuse:

Such treatments are excluded from health insurance coverage.

11. Treatment Received in Nature Cure Clinics, Health Hydros and Spas:

Treatment in such similar establishments are excluded from medical cover. 

12. Unproven Treatments:

Treatments that lack medical evidence to support their effectiveness will not be provided coverage.

13. Sterility and Infertility:

Expenses for contraception, sterilization, assisted reproductive services, gestational surrogacy and reversal of sterilization are excluded from coverage.

14. Maternity:

Medical expenses for childbirth, like complicated deliveries and Caesarean-section will not be provided coverage. The only exception is ectopic pregnancy, where the foetus develops outside the uterus. Miscarriage expenses, unless resulting from an accident along with costs of lawful termination of pregnancy will not be covered.

15. Ancillary Hospital Charges:

Accompanying hospital charges, like costs of admission, discharge, administration, registration, documentation, surcharges, RMO charges, night charges, service charges etc. are excluded from health insurance coverage.

16. Circumcision:

Unless required as part of medical treatment, this procedure won’t be covered. 

17. Conflict and Disaster:

The new health insurance coverage exclusion list also excludes any illness or injury due to war, rebellion, armed resistance, acts of terrorism and nuclear or radiological emissions.

18. External Congenital Anomaly:

External abnormalities to a new-born baby, like cleft lip are excluded from coverage.

19. Dental/Oral Treatment:

All treatment and procedures related to disease of natural teeth and gingiva, unless required by an insured person while being hospitalized due to an accident, are excluded from coverage.

20. Hormone Replacement Therapy:

Such treatment for an illness/disease is excluded.

21. Costs of Medical Equipment to be Used at Home:

Coverage will not be provided for the costs of multifocal lens and ambulatory devices, like walkers, crutches, splints etc.

22. Sexually Transmitted Diseases:

Any medical costs related to STDs, except for AIDS, will not be provided coverage.

23. Sleep Disorders:

Treatment costs of sleep abnormalities will not be covered.

24. Treatment outside India:

Any medical services availed in a foreign country will not be covered as per the new health insurance coverage exclusion list.

25. Unrecognized Physician/Hospital:

If a doctor, not recognized by the MCI or Central Council of Indian Medicine, provides treatment, coverage will be denied. Similarly, treatment by a hospital, which is not recognized by relevant authorities, is also outside the ambit of coverage. This clause also excludes treatment by a doctor, who either lives with the policyholder, or is an immediate family-member.

26. Artificial Life Maintenance:

The health insurance cover will not be provided to policyholders who have been declared brain dead or are in a vegetative state. 

27. AYUSH Treatment:

Any form of alternative treatment, unless expressly mentioned in the policy document, will not be covered.

28. Cost of Dietary Supplements:

Unless prescribed by a medical practitioner as part of medical treatment during hospitalization or as day care procedure, the cost of purchasing dietary supplements cannot be claimed under the policy.

Conclusion:

Healthcare insurance exclusions can leave you vulnerable to high out-of-pocket costs if you have an unexpected medical emergency. To ensure that you and your family are protected against the financial burden of medical expenses, it is important to carefully review your health plan. As seen above, it is important for healthcare insurance policyholders to stay up to date about any changes in the regulations by IRDAI. This will help the policyholders know what is included and excluded in their coverage. Additionally, speak with a licensed healthcare insurance agent to help you determine what type of coverage is best suited to meet your needs. With the right coverage, you can rest assured that you and your family are financially prepared for the unexpected.