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6. What does a Health Insurance policy not cover
If your family or a local doctor does the treatment of your illness and you do not need to be hospitalised, then in most cases it will not be covered by the company. If any of the diseases requires you to be hospitalised, then the insurance company will take the requisite steps as per the terms and conditions of the contract.

For instance: If a person meets with an accident and breaks his leg, then he will be taken to an orthopaedic surgeon. Treatment will include the following:-

 Doctor fee                    700

After the treatment, patient is suggested to have a bed rest for 21 days. In this situation, health insurance will not cover the expenses you paid.

According to a public sector health insurance company, following are the treatments which are not covered from their end:-

  • All the pre-existing diseases and injuries will not be covered. Those who need to apply for this condition, they must take the date of inception of the entire Mediclaim policy taken from any Indian insurance company. However, they must ensure that the renewal should be continuous and without any break or delay.
  • During the first year, the expenses of the following treatments:-

    1. Cataract,Benign Prostatic Hypertrophy,
    2. Hysterectomy for Menorrhagia or Fibromyoma Hernia,
    3. Hydrocele,
    4. Congenital,
    5. Internal disease,
    6. Fistula in anus,
    7. Piles,
    8. Sinusitis

Apart from the aforementioned, quite a few other disorders are also not payable.

1) Disorders and injuries occurred directly or indirectly from Invasion, War, Battle or War like operations.

2) Circumcision unless it is necessary for the treatment of a disease or which may occur due to an accident, vaccination or inoculation or change of life or cosmetic or aesthetic treatment of any description, plastic surgery other than which may become necessary due to an accident or as a part of any illness.

3) Spectacles and contact lenses.

4) Any dental treatment or surgery that doesn't involve hospitalization.

5) Convalescence, general debility 'Run-down' condition or test cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohol.

6) Any form of expense arising due to Human T-Cell Lymphotropic Virus type III (IITLB-III) or Lymphadinopathy Associated Virus (LAV) or the Mutants Derivative or Variations Deficiency Syndrome or any Syndrome such as AIDS.

7) Charges incurred in the hospital for X-ray or laboratory examinations and treatment of the diseases like any ailment, sickness or injury for which you need the confinement at a hospital and nursing home.

8) Money spent on vitamins and tonics unless it is certified by the attending physician.

9) Injuries caused by nuclear weapons will also not be payable.

10) Treatment arising because of pregnancy or childbirth will also not be suffered by the company.

11) Voluntary medical termination of pregnancy from the date of conception, during first 12 weeks.

The lists actually vary from companies to companies, so when you get an insurance done, do ask for the latest list.

Maternity :-
All the insurance companies added maternity hospitalization in the list in 2004. However, they started provided the similar services only under group insurance. That means, if you have a group insurance then the maternity expenses will be automatically paid by the company. But one should not expect maternity insurance in an individual policy. Actually, the corporate going for the group insurance pays extra for the maternity cover.

Pre-Existing Diseases :-
Pre existing is very rarely covered . Some companies cover pre-existing after you have been in the policy for a few years.

How to Select a Health Insurance Product or Company?
Today, advertisements promote every brand and product. Similarly, health insurance companies are also focusing on endorsing their products aggressively. But this doesn't mean that you have to be a part of this overcrowded market.

With very aggressive sales, the insurance companies are finding that the claim ratio have gone up to as high as 140%+, Consequently, most of the companies have become more careful in increase their exposure to this risk. Recently, the public life insurance companies have stopped cashless claims in many major hospitals.

Lately, some of the PSU's emerged with latest instructions mentioning under which agent commission should not be paid if the insured is 50+. So this is clear that they certainly don't want to promote their product amongst the groups that contains people above 50 years of age and focusing on adolescents and young generation. This is predominantly being done to reduce the risk and also to enlarge the portfolio.

Following are the common reasons that these insurance companies give after their proposals get rejected:-

1) Individual Proposal: Generally, the stand-alone cases are not covered. However, the similar kind of individual proposals for the families are acceptable.
2) 50+ Age: Those are above 50+, we are not covering risks for them. So it should be below 50.
3) Pre-existing Diseases: If they wouldn't be having any pre-existing disease, we would have covered it. People suffering from heart diseases encounter this problem every time they try to opt for a health insurance.
Taking into account the above information, you should decide on what basis you would like to select an insurance product and company.

1) Hospitals which are listed and associated with the Insurance Company in your city of residence
2) Considering this data, you can approach mulitple Insurance companies and there are chances that your proposal will be accepted (for the insurance of the four people).

Let's take an example here:-

Name of family Members Age Pre-existing Diseases   Sum-assured
A52DiabetesRs. 1,00,000
B47NoneRs. 1,00,000
C22NoneRs. 1,00,000
D16NoneRs. 1,00,000

Option 1: If you talk about this case, most of the insurance companies will not cover A's diabetes. It will be considered as a pre-existing disease.

Option 2: In case the proposal is not accepted by the Insurance company, one can approach another service provider. Most of the insurance companies will surely cover B,C and D but not A. However, it is difficult but not impossible.

Premium Calculation

A19001900 (Diabetes not covered)
 Less Family Discount 620620
Premium Payable55805580

In this example, if the policy is renewed for next 4 years that too without any claim then this heart disease exclusion will also be deleted from the 5th year. In example 2: the choices are there with you.

Simply accept the policy with diabetes as a pre-existing disease. And complete 4 years without any claim and get the heart disease covered from the 5th (next) year.

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