Know what your health cover doesn’t pay for

When Mumbai-based Shweta Jaisingh (name changed) tried to buy a health insurance policy, her application was rejected. Jaisingh, who is in her thirties, said, “I suffer from rheumatoid spondylitis. The severity of my condition is 1/10, which means it is almost non-existent. But because the advice is that one should always declare previous illness, I declared it while applying for the policy.”

She was ready to for a higher premium or longer waiting period. But was not given any such option. “The issue is that rheumatism as a category is excluded from health insurance,’’ she added.

It is probably cases like this, which has forced Insurance Regulatory and Development Authority of India (Irdai) to start the exercise to minimise the number of illness and diseases whose expenses are not covered under health insurance policies. These diseases/ailments are called exclusions. 

But whether the committee will provide relief to patients like Jaisingh is yet to be seen. According to a senior official from a general insurance company, the committee’s role is to not get into what insurance companies should and should not cover, but to address the ambiguous wordings insurers use. “Today, the regulator does it on a case-to-case basis when products are filed. But there should be framework for such exclusions,’’ he said. 

While the type of insurance policies have risen, exclusions, too, have increased. With tough-to-understand medical terms being used for exclusions, medical insurance customers often discover only at the claim stage that the insurer will not cover these expenses. With the hospital already having billed those so-called 'non-billable' expenses, there is no other way but to pay the money from own pocket. DNA Money tells you about other dreaded exclusions like rheumatism.

Commonly excluded conditions and diseases

To begin with pre-existing diseases are not covered by most medical insurance policies. So, if you fall sick due to such ailments, you will have to pay the money on your own unless the hospitalisation occurred after 24-48 consecutive months of continuous coverage.

Many insurance policies do not pay for any disease contracted during the first 30 days from the commencement date of the policy. But even if you fall sick after the 'cooling off' period, there is no guarantee that all your expenses will be reimbursed. While policyholders can understand insurers not covering the cost of spectacles and contact lens, hearing aids, walkers, dental treatment or surgery unless necessitated due to accidental injuries and requiring hospitalisation, there is a long list of exclusions of diseases that can happen to almost anybody.

Customers cannot be blamed for believing that insurers are designing policies that try to duck claims. For instance, a senior citizen health insurance policy has exclusions like cataract, ENT related diseases, hernia, gallbladder and pancreatic diseases etc. These are diseases which mostly occur after 60 years. Some diseases and ailments happen due to hereditary or genetic reasons. For instance, a family medical cover has exclusions like autoimmune disorders, congenital anomaly, hereditary or genetic disorders etc. What will people do if they find their children affected with such disorders?

Many insurers do not pay for expenses for treatment of degenerative disc of vertebral diseases, varicose veins and ulcers, sinusitis, tonsillitis, nasal polyps and fistula, among others. All treatments, for hepatobilary gall bladder, pancreatic stones and genito-urinary calculi are also excluded. Dysfunctional uterine bleeding, fibroids, pelvic inflammatory diseases, all diseases of fallopian tubes and ovaries, etc, are also excluded by some insurers. 

Insurers also use terms like convalescence, general debility, nutritional deficiency states, psychiatric, psychosomatic disorders, etc that are excluded. Plus, insurers have clauses in their policies that exclude expenses 'for investigation/treatment irrelevant to the disease'. Hospitalisation cost for 'evaluation and diagnostic purposes' are a strict no-no, even if required.

Exclusion terms are difficult to understand

The key issue with current exclusions in health insurance plans is that they are quite technical and non-uniform from a customer’s point-of-view. A normal customer’s ability to understand the boundaries of what is excluded and what is included is limited, which could leads to claim rejection.

"There is no standard definition of exclusions like ENT diseases, motor neurone diseases, etc. Standardising and minimising exclusions will help both the customer and the company, by streamlining the whole process with more transparency and trust," said Vaidyanathan Ramani, head product and innovation, Policybazaar.com.

Why insurers exclude some ailments

According to Vikas Mathur, head – health, Universal Sompo General Insurance said that exclusions help keep premiums fair by eliminating the possibility for unusual high risk events.

"Conditions like diabetes mellitus, hypertension, etc, pre-existing to the policy are covered after three to four years. Few listed surgeries are covered after waiting periods of one to two years, which again are termed as time bound exclusions. Both these vary from from insurer to insurer," he said.

Permanent exclusions

Some diseases/ailments are termed as permanent exclusions. Diseases like HIV, congenital external diseases, etc, are usually permanently excluded. Dental surgeries other than due to accidents, cosmetic/aesthetic surgeries, etc, are excluded from health insurance policies.

Ashish Mehrotra, MD & CEO, Max Bupa Health Insurance, said: "Irdai’s latest initiative to reduce health insurance policy exclusions and standardise the nomenclature will encourage health insurance uptake and bring more people under the gamut of health insurance coverage.”

Also, at present, many policies do not pay for certain hospital services/articles separately. For example, X-Ray film is payable under radiology charges, but not as consumable. Blood grouping and cross matching of donor samples is considered part of cost of blood and not payable. If you require more than one urine bag in 24 hours, the policy will pay for one bag only. Oxygen mask cost is not payable. Ambulance collar, and ambulance equipment is not payable. There are also a whole host of non-medical charges that are not paid such as cost for blood reservation charges, documentation/administrative charges, medical records, etc.

WHAT IS NOT COVERED

• Pre-existing diseases are not covered by most insurers up to two-four years of continous coverage
   
• Any ailment contracted within 30 days of commencement of policy
   
• Degenerative disc of vertebral diseases, varicose veins and ulcers, sinusitis, nasal polyps and fistula
   
• Expenses for investigation/treatment irrelevant to the disease  
   
• Non-medical charges or hospital services/articles