What Are Exclusions in Health Insurance?

Health insurance policies protect you from unexpected medical expenses, but they don’t cover everything. The IRDAI has standardised health insurance exclusions, and this ensures that pre-existing conditions are covered after completion of a waiting period. 
Certain conditions, like chronic liver disease, epilepsy, and pancreatic disease, may be permanently excluded. Let’s get into more details on common exclusions in health insurance policies.

Contents

• What Are Exclusions in Health Insurance?
• Types of Exclusions in Health Insurance
  • 1) Standard Exclusions
  • 2) Permanent Exclusions
  • 3) Maternity & Newborn Exclusions
• Common Exclusions in Most Health Insurance Policies
  • 1) Pre-Existing Diseases
  • 2) Self-Inflicted Injuries
  • 3) Alcohol or Drug-Related Issues
  • 4) Transmitted Diseases
  • 5) Infertility Treatment
  • 6) Pregnancy-Related Treatments
  • 7) Congenital Disorders
  • 8) Dental, Vision, and Hearing Problems
• Conclusion
• Frequently Asked Questions 

What Are Exclusions in Health Insurance?

Before finalising a policy, you must be clear about what are exclusions in health insurance. The exclusions in health insurance policies refer to medical treatments or conditions that are not covered by a health plan. The exclusions in health insurance may also slightly vary from insurer to insurer.

Types of Exclusions in Health Insurance

Here are the different types of health insurance exclusions:

1) Standard Exclusions

These exclusions are common in most health insurance plans:

• If you had a health issue before buying the policy, you may have to wait before it gets covered.

• Costs for medical tests performed just to check your health (without treatment) are not covered.

• Certain treatments, like joint replacement or cataract surgery, may have a waiting period.
  Injuries from risky activities like rock climbing or racing are not covered.

• If you require prolonged nursing or rehabilitation, the policy may not pay for it.

• Unless it's required after an accident or a health condition, insurers won’t cover cosmetic or dental procedures.

• Surgery for weight loss is commonly not covered unless it is medically necessary.

2) Permanent Exclusions

The permanent exclusions in health insurance include:

• Injuries caused by intentional self-harm are not covered.

• Costs for alcoholism or drug rehabilitation are excluded.

• Some policies have an exclusion in insurance for birth defects, i.e. they don’t cover birth-related health conditions.

• One of the common permanent exclusions in health insurance is the treatments related to infertility or contraception.

• If a treatment is not officially approved, the policy will not cover its expenses.

3) Maternity & Newborn Exclusions

Some health insurance plans may not cover maternity-related hospitalisation. Similarly, newborn care could also be excluded. If you are planning a family or looking for this coverage then do confirm this coverage with your health insurance company.

Common Exclusions in Most Health Insurance Policies

The common exclusions in a health insurance plan are described below. These conditions are not covered under a mediclaim policy.

1) Pre-Existing Diseases

Pre-existing disease means a medical condition or illness you have already been diagnosed with before purchasing a health insurance policy. Insurers may not cover such diseases immediately. 

2) Self-Inflicted Injuries

Injuries caused by intentional self-harm are considered health insurance exclusions. It is one of the common health insurance exclusions, and it intends to convey that coverage is typically provided for unforeseen circumstances, not for self-inflicted injuries.

3) Alcohol or Drug-Related Issues

Health plans do not cover treatments for illnesses caused by smoking, alcohol, or drug misuse. The purpose is to encourage responsible behaviour.

4) Transmitted Diseases

The common health insurance exclusions related to transmitted diseases are HIV and AIDs, hepatitis, and syphilis. But some insurance plans provide treatment coverage through specialised policies.

5) Infertility Treatment

Procedures like IVF (in-vitro fertilisation) and fertility treatments are not covered as exclusion in insurance coverage.

6) Pregnancy-Related Treatments

Standard health insurance plans do not cover pregnancy expenses unless maternity benefits are included. Certain group health insurance plans do offer maternity coverage. 

7) Congenital Disorders

Health issues existing from birth are often excluded. But some insurers provide coverage through add-ons.

8) Dental, Vision, and Hearing Problems

Most health insurance policies do not cover eye, dental, or hearing treatments unless hospitalisation is required. You can opt for add-ons to get coverage for such treatments.

Conclusion

A thorough understanding of what are exclusions in health insurance will minimise the chances of claim rejection. These exclusions assist insurance companies in preventing high-risk cases, provide affordable rates, and stop policyholders from using their policy coverage unfairly. Make sure to carefully go through the policy document to stay prepared for any medical emergency. 

Frequently Asked Questions 

In this section, we will go over some of the most frequently asked questions about Exclusions in Health Insurance

Can I claim it if my condition is excluded?

No, your insurer will not cover the condition that is categorised as an exclusion. But pre-existing conditions may be covered after a waiting period.

Will all health insurance policies have the same exclusions?

It is not mandatory that all health insurance policies have the same exclusions. Make sure to review your policy document for details to have clarity on exclusions in health insurance.

Can exclusions be removed through riders or add-ons?

Yes, you can waive some exclusions through riders or add-ons. For instance, alternative treatments and maternity coverage can often be included via additional premium payments.

How are pre-existing conditions treated under exclusions

Generally, pre-existing diseases have a waiting period, ranging from 2 to 3 years before coverage starts.

Is cosmetic surgery ever covered by health insurance?

Generally, health insurance policies exclude elective cosmetic procedures. But it may be covered if the surgery is doctor-recommended.

Recent

Articles

Life Insurance Cash Value: Savings Component That Builds Over Time in Permanent Policies

Neviya Laishram Jul 30, 2025

What is an Actuary in Insurance and What are their Roles & Responsibilities?

Neviya Laishram Jul 29, 2025

What is Life Assured in Life Insurance?

Neviya Laishram Jul 23, 2025

What is a Lapsed Policy in Life Insurance?

Neviya Laishram Jul 22, 2025

What is Keyman Insurance?

Neviya Laishram Jul 22, 2025

All Articles

Topics

Life Insurance Glossary

Life Insurance Glossary

Life Insurance Glossary

Life Insurance Glossary

Life Insurance Glossary

All Topics

Want to post any comments?