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6 Things do not cover by your Health Insurance Policy

6 Things do not cover by your Health Insurance Policy

When we buy Health Insurance, sometimes it becomes difficult for us to understand the complex terms and conditions of the policy. Despite increasing awareness about sub-limits, pre-existing diseases, and other exclusions, the policies claim denial or reduced payouts continue to shock. To ensure uniformity, the IRDAI (Insurance Regulatory and Development Authority of India) has set up a committee to suggest measures to standardize exclusions. In 2012, the regulator listed 199 items, indicating their admissibility or otherwise. The recent move aimed at streamlining the framework further. Till then, here is a list of 6 things do not cover by your Health Insurance Policy:

New or advanced treatment procedures:

In this time of globalization, every day many new techniques and treatment procedures are introduced. But Insurance companies take time to keep pace with them. Now, when you claim for various forms of surgeries if the hospitals recommend robotic surgery or cyber knife, which are not part of the policy agreement. The claim not covered and becomes a part of exclusions. Stem cell therapies also not covered either. As a policyholder, the key is to go through policy wordings to know if the ‘advanced’ treatment procedure your doctor is recommending covered by your insurer or not.

Resident doctor’s charges:

If your hospital segregates room rent and resident doctor’s charges in the bill, chances are your insurer will not foot it. Technically, resident doctor’s charges suppose to include in the room rent. Therefore, the insurer will not pay for any separate resident doctor’s charges. Since an individual can rarely dictate a hospital’s pricing policy, the best bet would be to choose a network hospital at least for planned or non-emergency hospitalization. Network hospitals are in tune with insurer’s policies. Hence the scope for the high proportion of non-payable expenses in bills limited. Registration charges levied by the hospital at the time of admission will also not approve. Admission deposit not covered either. Most are usually not aware of nonpayable consumable items like shampoo and powder and other non-medical items. These form part of the standard list of nonpayable items as per regulations.

Multiple visits by specialist doctors in a day:

In the insurance policy, it may or may not cover the multiple visit option. While we pay for charges related to all visits of specialist doctors, some products do not pay for multiple daily visits by the same specialist. For example, the policy may pay for one day visit of say a gastroenterologist, a neurologist, and a nephrologist, but not if the same specialist visits the patient more than once a day. This, despite the fact that a patient may need multiple consultations during a day.

Certain drugs used during hospitalization:

Despite being a critical illness, there is no blanket approval for all the treatment procedures meant for fighting cancer. Some Insurance companies excluded certain cancer drugs. For example, a few chemotherapy drugs when administered intravenously are covered but if taken orally will be outside the scope of cover. Similarly, most drugs that fall under the umbrella of immunotherapy not covered. Some policies may not pay for administration of intra-articular or intralesional injections. In addition, expenses related to supplementary medications are also not admissible.

Illnesses as a result of substance abuse:

You may be suffering from a critical disease, but if it is evident that the cause was alcohol abuse or excessive smoking, you might have to pay for the expenses out of your pocket. However, this can be tricky. Sometimes, claims repudiated on the grounds that the ailment caused by alcohol abuse or smoking. If you do not agree, you can raise a dispute. The causation established for such rejections.

Treatment at home:

If the insured person is unable to admit to hospital, several insurers cover treatment at home. A medical treatment for a period of over three consecutive days for a condition which would otherwise require hospitalization; but taken at home, called Domiciliary Hospitalization. In such cases, the payable expenses usually capped at 10% of the sum assured. However, it’s completely disallowed in case of some diseases like asthma or bronchitis, even if the patient meets other criteria for allowing treatment at home.

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