Health insurance is a boon when used the right way. This requires a thorough understanding of what it can and can’t do for you as a policyholder. You may think that once you purchase a health insurance policy, every trip to the hospital will be taken care of by the insurer. While this is true to an extent, it is not entirely correct to assume this. Insurers have put in place certain conditions and clauses that are aimed at providing care in a fair and sustained manner to policyholders. Medically necessary treatments are one such concept that policyholders need to be aware of. Here’s what you need to know about such treatments.
Plans start at just ₹21/day*.
We pay 100% of your hospital bills
From syringes to surgeries
No limit on hospital room rent
No compromises on recovery
A health insurance policy will only cover a treatment that is considered to be “medically necessary.” It can be defined as any treatment, test, medication, or hospital stay that is required for the medical management of an illness, disease, or injury of the policyholder or their dependents. These treatments are considered to be standard practices among the medical community in the country to manage a patient’s condition. Failure to carry out such treatments may have a detrimental impact on the patient’s health. They are not performed for the convenience of the patient nor the healthcare provider, but to actually improve and manage a patient’s health outlook.
Here are some procedures that are considered to be medically necessary by most insurance companies.
Surgeries such as cataract surgery, appendectomy, gallbladder removal, and orthopaedic surgeries are considered to be medically necessary. They are required to improve acute conditions, and failure to do so can hurt the patient’s overall health.
Emergency hospitalisations and treatments are considered to be medically necessary; it is a matter of life and death in many cases. This could include visits to the emergency room for heart attacks, strokes, and accidents.
Cancer treatments, including radiation, chemotherapy, and surgery for tumour removal, also fall under this category. Cancer is a critical illness, and its treatment is considered to be life-saving.
Treatments to improve heart disease, such as angioplasty, bypass, and pacemakers, are key to saving a patient’s life and hence considered to be medically necessary by the medical community and insurers.
Procedures aimed at protecting the functioning of the kidney, such as dialysis and a transplant, are medically necessary.
While some procedures are considered to be medically necessary, there are others that the insurance company will not cover. You will have to pay out of pocket for these procedures, as any claims raised for such procedures will be rejected by the insurer. Here are some of the treatments that are excluded from coverage, including those that fall under a waiting period:
Plastic surgeries, including nose jobs, face lifts, hair transplants, breast augmentation, Botox, fillers, etc., will not be covered by a standard health insurance policy. When these are done for the sole purpose of enhancing the policyholder’s physical appearance, it is deemed to be unnecessary. But if they are required as a part of treatment in case of an accident, insurance can provide coverage for these procedures.
Diseases that are spread through sexual contact are considered to be uninsurable. Even though some may require intense medical care, the treatment for such diseases is considered to be a high financial risk to insurers, as they can be very expensive and require prolonged care
Any treatment that is required to address injuries sustained due to an episode of self-harm or suicide attempt cannot be covered under health insurance.
Pre-existing conditions such as diabetes, hypertension, and heart disease are not eligible for coverage within a waiting period set by the insurer. This could be anywhere between 1 and 3 years and varies from insurer to insurer. Any medical expenses incurred during the waiting period for pre-existing conditions will have to be borne by the policyholder. This changes once the waiting period is completed, with the insurer providing coverage for these conditions.
If a treatment is considered to be medically necessary for the policyholder, the insurer is more likely to approve the claim than reject it.
If the treatment is deemed to be unnecessary, the insurer can reject the claim. You will have to pay out of pocket in such cases.
The insurer may ask for additional documentation in order to ensure that the treatment is medically necessary. Failure to produce proper supporting documents can result in claim rejection.
It is very important to keep track of what is considered medically necessary when it comes to your medical claims. Failure to do so comes at a very heavy price. Always read your health insurance policy document carefully and talk to your insurer about such treatments to ensure that you know what is excluded and included in your policy.
2.5K Linkedin Followers 
Reviewed by Dr. Harshita Dahiya 
Acko Technology & Services Private Limited
#36/5, Hustlehub One East, Somasandrapalya, 27th Main Rd, Sector 2, HSR Layout, Bengaluru, Karnataka 560102
Products 
Company
Legal
Support
Car Insurance 
Bike Insurance
Health Insurance
Group Health Insurance
Travel Insurance
Life Insurance
