Health insurance exclusions are terms and conditions that exclude some expenses from health insurance coverage. Since elders are more likely to have medical conditions, their policies are subject to strict scrutiny, higher premiums, and limited coverage. Understanding these exclusions that result in limited coverage in insurance is important to make informed decisions.
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Policy Exclusions & Coverage Limitations for Seniors in Health Insurance
Until April 2024, most insurers didn’t allow seniors above 65 years to get health insurance. IRDAI removed the age limit ceiling, allowing everyone in India, irrespective of their age, to get coverage.
Although this limit has been removed, many such exclusions are common features in senior health insurance policies.
These exclusions outline what health problems are not covered, meaning seniors and their families could face considerable unexpected extra bills. As a result, ensuring you understand policy exclusions remains vital, although the age limit has increased.
Even though health insurance policies have different terms and conditions, you will find these common policy exclusions across many insurance plans:
The waiting period clause includes specific medical conditions that will be covered only after a certain number of years have passed. Some medical conditions that are commonly a part of the waiting period clause are hypertension, diabetes, high or low blood pressure, and asthma.
Procedures that are purely cosmetic or intended solely for dental improvements, such as plastic surgery or implants, are typically not included in senior health insurance plans.
AYUSH therapies that include Ayurveda, Yoga, Unani, Siddha and Homoeopathy are not included in many policies.
These are expenses incurred during the diagnosis of a medical condition. Standard examples include blood tests and X-rays.
Permanent exclusions include health problems caused by HIV, war, self-inflicted injuries, etc.
Unlike exclusions, sub-limits don’t entirely reject claims but place a cap on reimbursements for certain things.
Sub-limits can be placed on room rent caps and specific surgeries. Consider an example of Avinash, aged 65 years, who underwent a simple surgery for gastrointestinal problems. The cost of surgery was ₹45,000. However, his policy had a sub-limit of ₹38,000 on that particular surgery. In this case, Avinash will have to pay the additional ₹7,000 out of pocket.
For senior citizens, reading the fine print means knowing the difference between coverage and exclusions.
The terms and conditions mentioned in a policy define claim processes, exclusions, co-payment clauses, and network hospital rules. Understanding all these terms and reviewing your policy regularly helps ensure that your insurance needs align with the coverage.
It also helps you stay informed about policy changes and potential cost savings. For instance, you can review your existing policy and an insurance plan offered by some other insurer. This can enable you to port to an insurer who offers better coverage at a reduced cost.
Here are some of the ways to overcome the gaps:
A top-up policy kicks in after the main policy’s limit is exhausted. These plans are affordable and help extend the coverage in insurance.
As the name suggests, these riders are for critical illnesses like stroke, kidney failure, or cancer. When you are diagnosed with any critical illness mentioned in the policy, this rider provides lump-sum payouts to help with costly long-term treatments.
Keep a health emergency fund because it may be helpful in case of unexpected rejections or exclusions. Having some savings to tap into can especially come in handy during emergency situations.
Always prefer network hospitals for treatments to reduce initial out-of-pocket expenses.
Exclusions will be a part of any health insurance policy you buy. However, seniors usually face more limits and exclusions due to their high vulnerability to diseases. This makes it even more important to understand their health insurance coverage and exclusions to avoid any surprises. Review your health policies regularly and be aware of all the exclusions to reduce the gaps between your needs and the health coverage.
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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
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