What is covered and what is not?

Details on coverage in an Insurance Policy

What is covered
Health Insurance covers hospitalization expenses incurred as an in-patient in a Hospital which will include: Room, Boarding and Operation Theatre charges; Fees of Surgeon, Anesthetist, Nurses, Specialists; and the cost of diagnostic tests, medicines, blood, oxygen, appliances like pacemaker, artificial limbs and organs etc.  Hospitalization for a minimum period of 24 hours is a must.

What is NOT Covered
It is more important to know what is not covered in most of the insurance policies. While one must read the exclusion since it can vary from policy to policy, the general exclusions are:

  1. Congenital (by birth) and Pr-existing diseases (PED). The per-existing diseases are those illness which one suffered at time of taking of the policy. These may be declared or undeclared. The basic principal of Insurance is of Utmost Faith, the policy is issued based on the declaration given by insured, however at time of claim, if the illness is found to have existed prior to date of signing of the application form, the claim is rejected. However in case insured declares the illness and Insurance company accept and underwrite the same, PED are waived from 4th continuous year of the policy.
  2. Expenses incurred on alternative form of treatment like Naturopathy, Ayurvedic, Homeopathic etc.
  3. Dental – unless required due to accident
  4. Obesity related
  5. Cosmetic surgery, etc.

There are certain exclusion for first / second or up to fourth year. Please refer to Exclusion clause in the policy carefully before you handover the cheque and purchase your next policy.

The objective of the exclusion is that these are diseases which a person may be carrying at time of taking up the policy and treatment / surgery may be postponed for year or more. Most common illnesses are cataract, Hernia, hydrocele, piles etc.

Young couple look for maternity coverage, which is either not covered or covered after a waiting period of 2 years (for eg. Max Bupa ) to 4 years (Exclusive plan from Apollo Munich) the coverage varies from company to company for eg. For normal delivery Apollo allows expenses upto Rs 25000 and for caesarean delivery upto Rs 40000/-, Max Bupa allows expenses upto Rs 50000/-.  Maternity expenses are normally paid for two deliveries only.

As already mentioned, most of insurance companies allow day care surgeries to be covered. However one must look into number of day surgeries that are covered by Insurance company. Max Bupa covers all the day care surgeries, Apollo Munich specifies 146 surgeries where as ICICI Lombard specifies only 9 day care surgeries.

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