Health Insurance Exclusion List Updated from IRDAI

When you buy health insurance, you likely focus on the sum insured or the list of network hospitals. However, understanding what is not covered is just as critical as knowing what is.

The Insurance Regulatory and Development Authority of India (IRDAI) has standardised guidelines to ensure transparency, making it easier for you to navigate medical insurance exclusions without hidden surprises.

Conditions such as epilepsy, HIV/AIDS and treatments like cosmetic surgery and weight loss surgeries are permanently excluded from health insurance. Keep reading to know more.

What are Health Insurance Exclusions?

Health insurance exclusions refer to specific conditions, treatments, or situations for which your insurer will not provide coverage or pay for expenses. Directly put, these are the no-go zones of your policy.

IRDAI updated these exclusions, effective from April 1, 2024, to prevent confusion and ensure that every insurer uses the same language. By knowing these, you can plan your finances better and avoid claim rejections during medical emergencies.

What are the Permanent Exclusions in Health Insurance According to IRDAI?

There are certain high-risk or chronic conditions that an insurer might never cover. These are known as permanent exclusions in health insurance.

Under the updated IRDAI guidelines, insurers can permanently exclude specific diseases only if the applicant discloses them during underwriting and the insurer’s policy prohibits coverage even with an extra premium.

So, if you are wondering what are the new medical insurance exclusions then keep reading the list below:

1. Epilepsy: It is a chronic neurological disorder where the brain experiences seizures due to sudden and abnormal electrical activity.

2. Inflammatory Bowel Disease: Several diseases, such as Crohn’s disease and ulcerative colitis, fall under this. These cause inflammation in the digestive tract.

3. HIV and AIDS: Human Immunodeficiency Virus (HIV) destroys CD4 cells, which in turn weakens the immune system. It leads to AIDS.

4. Chronic Liver Disease: This is a progressive condition where chronic inflammation in the liver causes fibrosis (scarring) and cirrhosis.

5. Cerebrovascular Disease (Stroke): It refers to a group of conditions which affect the blood vessels in one’s brain. Examples include stroke, aneurysms, etc.

Other diseases include sarcoidosis, malignant neoplasms, heart ailment, congenital heart disease, pancreatic diseases, hepatitis B, demyelinating disease, valvular heart disease, loss of hearing and avascular necrosis.

If you have these conditions, your insurer will evaluate them during your application. If a permanent exclusion is applied, it will be clearly mentioned in your policy schedule with your consent.

What are the Common Medical Insurance Exclusions?

According to an Economic Times report, India’s health insurance sector is losing ₹8,000 crore to ₹10,000 crore annually due to fraud (BCG and Medi Assist). These not only strain insurers’ stability but also push premiums. Therefore, standardising medical insurance exclusions helps avoid fraud.

Change of Gender (Code: Excl 07)

Gender-affirming surgery (GAS) refers to a personalised and multidisciplinary surgery that aligns someone’s gender identity with their physical characteristics. If you opt to have such surgery, then your insurer will not cover the expenses.

Pre-Existing Diseases (Code: Excl 01)

This is a well-known health insurance exclusion which defines any disease that you have before buying the insurance. You must declare any disease that you have before buying a policy. After a certain time (usually 3 years), your insurance policy will start covering them.

Investigation and Evaluation (Code: Excl 04)

Under exclusion code Excl04, health insurance strictly denies hospital admissions meant solely for diagnostic or evaluation purposes. This means you cannot get compensation for any diagnostic expenses or tests that do not directly relate to, or are not incidental to, your current diagnosis and active treatment.

Rest Cure, Rehabilitation and Respite Care (Code: Excl 05)

If you are wondering what is a permanent exclusion in health insurance then you can count on this one. IRDAI excludes custodial care for daily living assistance and holistic services for terminally ill patients. However, insurers may offer specific add-on riders for home or respite care, particularly designed for continuous policyholders aged 65 and older.

Obesity and Weight Control (Code: Excl 06)

Any kind of weight loss and thinning surgery will be excluded from your health insurance policy. However, there is a catch to it. If your doctor prescribes this surgery, your Body Mass Index (BMI) is above 40, you have a serious disease, and you have tried to lose weight by other means with no success, then your insurer may reimburse you for the expenses.

Along with these, other medical insurance exclusions include:

1. Hazardous adventure or sport

2. Excluded medical provider

3. Breach of law

4. Cosmetic or plastic surgery

5. Unproven treatments

6. Maternity (unless specified in the policy schedule)

7. Birth control

8. Refractive error

What is the Concept of Waiting Period in Medical Insurance Exclusions?

When talking about what is medical insurance exclusion, you will often come across waiting periods. This means that your insurer will include some treatments only after you serve a certain period of time.

1. Initial 30-Day Waiting Period: Most medical insurance exclusions include a 30-day window from the start of the policy, during which your insurer will not cover anything. However, this does not apply to emergency treatments following an accident.

2. 2-year Exclusion for Health Insurance: Many policies implement a specific 2-year exclusion for health insurance regarding slow-growing ailments. This typically includes cataracts, hernia, joint replacements, and stones in the gallbladder or urinary tract.

3. PED Waiting Period: Your insurer will cover PEDs after a waiting period of 36 months. Before that, you cannot make a claim where the primary cause is a PED.

For Example: Rajesh, a 35-year-old software engineer who decides to buy a health insurance policy. The insurer accepts his proposal but applies Code: Excl 01 (Pre-Existing Diseases). This means Rajesh will have a 36-month waiting period specifically for diabetes-related complications.

What IRDAI Now Prohibits Insurers from Excluding?

In a move to favour policyholders, the IRDAI has listed several conditions that insurers cannot exclude anymore. This is a significant win for you, as it broadens your safety net.

1. Mental Illness: Your insurance policy must cover treatment for mental health, stress, or psychological disorders.

2. Genetic Disorders: Insurers can no longer place a blanket ban on genetic conditions.

3. Modern Treatments: Your insurer must include procedures like robotic surgeries, oral chemotherapy, and stem cell therapy (for bone marrow transplants).

4. Age-Related Ailments: Conditions like Age-Related Macular Degeneration (ARMD) cannot be part of medical insurance exclusions.

Why Must You Disclose Everything While Buying Health Insurance?

Honesty is the best policy. If you hide a condition to avoid a medical insurance exclusion, your insurer can reject your claim, stating 'Non-disclosure of Material Facts’.

However, when you disclose a condition, your insurer might still cover it after a waiting period or by applying a small additional premium (loading). This is much safer than having a claim denied during a crisis.

How Does the Moratorium Period Affect Medical Insurance Exclusions?

According to IRDAI, after you complete 5 continuous years with your insurer, they cannot deny a claim based on non-disclosure. However, they can do so if they uncover fraud on your part.

This provides you with long-term peace of mind, knowing that your older claims are secure from technical disputes.

Final Thoughts

Navigating medical insurance exclusions does not have to be daunting. By understanding the updated IRDAI guidelines, you can choose a plan that truly protects you.

At Bajaj General Insurance, we prioritise transparency so you always know what is covered. Review your policy document carefully, disclose your health history accurately, and ensure your family stays protected against the unexpected without any hurdles.

Download the Bajaj General app today and get a health insurance policy!

FAQs About Medical Insurance Exclusions

Can an insurer change the list of exclusions after I buy the policy?

No, the terms and conditions agreed upon at the start of the policy period remain valid until the next renewal. However, if IRDAI issues new mandatory guidelines, insurers must update their products accordingly, often benefiting the policyholder by reducing the number of allowed exclusions.

Is LASIK surgery covered under standard health insurance?

Generally, LASIK or refractive error correction is part of medical insurance exclusions if the error is less than 7.5 dioptres. Depending on your specific policy terms, your provider may cover the surgery if you require it for a higher dioptre or an injury.

Are dental treatments excluded from health insurance?

Most standard health insurance policies exclude dental treatments unless an accident necessitates them and requires hospitalisation. Policies typically exclude routine procedures like cleaning, fillings, or root canals unless you attach a specific OPD (Out-Patient Department) benefit or a dental-specific rider.

What happens if I am injured while playing adventure sports?

Treatment necessitated by participation in hazardous or adventure sports (like paragliding or rock climbing) is a standard exclusion. However, standard injuries from everyday sports are covered. If you frequently engage in adventure activities, check for specialised riders that cover high-risk sports.

Are diagnostic tests covered if I am not hospitalised?

Routine diagnostic tests (like blood tests or X-rays) without hospitalisation are usually excluded unless they are part of pre-hospitalisation expenses related to a later admission. Some modern plans with OPD covers do include these costs, so check your policy benefits for outpatient diagnostic coverage.

*Standard T&C Apply

Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions.

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

Claims are subject to terms and conditions set forth under the health insurance policy.