Understanding the Inclusions and Exclusions of Health Insurance Plans

Buying a health insurance policy is a tedious task as one has to compare various policies in order to select the best one. Turning pages of the policy documents in order to understand the terms and conditions is tough. Still, to obtain adequate health coverage, you must familiarise yourself with all of the policy’s key features.

“Inclusions” and “Exclusions” are two terms used in every health insurance policy which state the expenses covered and not covered by the insurer. This blog will cover the basic understanding of the same.

What is a Health Insurance Policy?

A health insurance plan is a type of insurance which covers the expenditure incurred on hospitalisation, doctor’s fees and various other medical expenses. It provides a certain amount of coverage on various diseases depending upon the plan an individual buys.

Inclusions

Inclusions are medical expenses that are covered by your insurance provider. Therefore, you can claim the amount against such healthcare treatments. Inclusions vary with the insurance company. Here is the list of common inclusions that you will come across while going through the policies:

Pre and Post Hospitalisation Expenses

All the pre and post-expenses of hospitalisation, including doctor’s fees, medical expenses, follow-up treatments and more, are covered in your insurance plan up to a certain time period which is mentioned in the policy document.

Annual Health Checkups

Annual checkups usually include tests for blood sugar, kidney function, ECG checkups and a few more. Insured members under the policy can avail of these checkups as mentioned in their policy once a year.

Daycare Treatments

Daycare treatments are the ones which require hospitalisation of less than 24 hours. Such treatments include cataract surgery, chemotherapy, dialysis and other operational services.

Cashless Admission Facility

In order to seek admission to any network hospital, you only require an identity card issued by the insurance company to the policyholder. This would not require any advance payments for the admission procedure.

Reimbursement of Medical Expenses

Even after your preferred hospital is not among the network hospitals, you can get yourself treated there and then submit your claim for reimbursement. This would require submitting original documents and bills as listed in the health insurance policy.

Exclusions

There are some exclusions which are not covered, and therefore, the insurer does not pay the claim for such treatments. Here is a list of common exclusions that you will come across while searching for a health insurance policy in India:

Pre-existing Diseases

If you have any medical history before purchasing a health plan, then the disease would not be covered under the policy for a certain period of time which is generally known as the waiting period.

Cosmetic Surgery

Any treatment which involves beautification, such as botox, facelift, lip augmentations, implants and many more, is not covered under the policy. Health insurance won’t provide claims against such treatments.

Dental Care

Dental treatments are short procedures which do not require hospitalisation. Therefore, most insurance providers do not include them in the policy.

Specific Diseases

Diseases such as sexually transmitted diseases, hernia, joint disorders etc., are not covered under the policy.

Diagnostic Charges

Doctor consultations, tests and various other procedures are required to diagnose the disease. The expenses in this process will not be covered by the insurer.

Alternative Treatments

Most insurance policies cover allopathic treatments. Alternative treatments like Ayurveda, Naturopathy, Acupressure and other such treatments are not covered under the policy. Thus, you cannot claim coverage against such treatments.

Life is uncertain, and having a good health plan can help you on your bad days. You should know the inclusions and exclusions to avoid conflicts at the time you need insurance the most.

It is advisable to read the policy documents thoroughly before making a purchase decision.