In this article, we will discuss some of the exclusions in insurance policies. So, let’s get started!What is an exclusion in an insurance policy?
Exclusions are the cases for which the insurance company does not provide coverage. These are the conditions excluded from the insured event to avoid losses to the company.Types of exclusion:
Exclusions in Health Insurance:
- Permanent Exclusion – claims for which the insurance company will never pay the amount.
- Time-bound exclusion – claims for which there is a waiting period (like pre-existing diseases) after which the company will consider the request.
1) Time-bound exclusion
Specific diseases time bound exclusion
- Expenses related to the treatment of any illness will not be covered within 30 days from the first policy commencement date.
- Pre-existing disease waiting period ranges from 24-48 months
- The enhanced sum will apply fresh pre-existing diseases exclusion.
- Apart from pre-existing diseases, there are a few specific diseases/procedures which will have 24 months of waiting depending on policies.
- If any of the specific diseases/procedures falls under the pre-existing diseases category then the higher of the two will be taken as exclusion.
2) Permanent exclusions
Exclusions in the term/Life Insurance
- Expenses related to any admission primarily for diagnostics & evaluation purposes will be excluded.
- Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
- Expenses related to admission primarily for bed rest and no treatment is received, Nursing facility for personal care like bathing, dressing, etc.
- Expenses related to services for people who are terminally ill address physical, social, emotional, and spiritual need
- Expenses related to surgical treatment of obesity & weight control are not advised by the doctor.
- Change of gender treatment.
- Cosmetic or plastic surgery.
- Hazardous or adventurous sports
- The person committing or attempting to commit a breach of law with criminal intent.
- Expenses incurred in a hospital or by a medical professional who has been excluded by the insurer. But in case of a life-threatening situation claim can be made only till the stabilization stage of the insured person.
- Expenses related to the treatment of alcoholism, drugs, or substance abuse.
- Supplements & substances which are not prescribed by medical professionals.
- Claims related to war, the person committing suicide, a person employed in armed forces
- Claims arising due to non-disclosure of pre-existing diseases or any material facts as declared at the time of buying the policy.
- Suicide claims will be excluded at any time within 12 months from the date of commencement except for 80% (mostly) of the premiums paid if any other charges are not applicable.
General exceptions when an insurer will not pay for a claim in Car insurance
- Claims which are made outside of the geographical area (ex – India)
- Claims for depreciation, wear & tear, mechanical & electrical breakdown etc
- Damage of tyres & tubes unless it is damaged at the time of an incident.
- Claims related to accidents when the person driving is under the influence of liquor or drugs.
- Claims arising from the use of a vehicle other than the vehicle is intended for usage.
- Claims arising for the vehicle which is not driven by the authorized driver by driver’s clause (ex - a person who doesn’t have a license for driving a bus)
- Any accidental claims toward damage or loss of a property.
- Any claim arising from any radioactive or nuclear material
- Any claims arising from war, rebellion, hostilities, etc.
Frequently Asked Questions:
1. Can an exclusion clause be transferred when applied for migration & portability in health Insurance?
Yes, time-bound exclusions diseases will be transferred till the period served on the previous insurance policy.
2. Are there exclusions in the company group insurance policy?
Yes, there can be time-bound exclusions or some permanent exclusions, depending on the policy the company has taken. If the company has opted to cover pre-existing diseases, then it will cover them from day one.
3. Can exclusion be avoided or reduced while buying insurance?
Some exclusion can be avoided like pre-existing diseases if the holder takes riders or pay higher premiums to the company. The policyholder can also find the policy which has the most minimum exclusion clauses but then the premium will be higher.
What Should Indviduals Do:
Exclusions in medical insurance policies are specific events or circumstances that are not covered by the policy. These exclusions may vary depending on the type of medical insurance you have, but common exclusions include Pre-existing conditions, elective/cosmetic procedures, alternative therapies, and experimental treatments. It is important to carefully review the exclusions in your medical insurance policy to understand what is and is not covered. If you have any questions about the exclusions in your policy, you should contact your insurance company or agent for clarification.