Health Insurance Exclusion List Updated from IRDAI

Health insurance policies offer you comprehensive financial support from unexpected medical emergencies. However, even though it includes a wide range of coverage for hospitalisation, sometimes you can't claim the benefits under certain circumstances.

This is why, to ensure you understand the medical insurance exclusions list, the Insurance Regulatory and Development Authority of India (IRDAI) has standardised guidelines. It helps you navigate exclusions without hidden surprises.

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

IRDAI have updated these exclusions 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.

Therefore, under the updated IRDAI guidelines, insurers can permanently exclude up to 16 diseases during policy underwriting. In fact, even with additional premiums, the applicants won't get coverage for these conditions.

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

1. Epilepsy
2. Inflammatory Bowel Disease
3. HIV/AIDS
4. Chronic liver disease, including those involving fibrosis or cirrhosis.
5. Cerebrovascular disease, such as  certain strokes
6. Sarcoidosi
7. Malignant Neoplasms
8. Heart Ailments
9. Congenital Heart Disease
10. Pancreatic Diseases
11. Hepatitis B
12. Demyelinating Diseases
13. Valvular Heart Disease
14. Loss of Hearing
15. Papulosquamous disorder of the skin
16. Avascular Necrosis

However, the permanent exclusion in medical insurance may vary across insurers and health insurance products. Even though IRDAI provides a standardised regulatory framework for exclusions, insurers may decide whether and how to apply permitted exclusions based on their underwriting guidelines and product terms.

Therefore, you should always check the policy wording and customer information sheet before purchasing a policy.

What are the Common Medical Insurance Exclusions?

The following section showcases some commonly standardised exclusion categories used in health insurance:

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 it.

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)

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.

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.

Cosmetic or Plastic Surgery (Code: Excl 08)

Health insurance only covers medically necessary conditions. Since cosmetic or plastic surgery is performed primarily to enhance appearance, it is not medically necessary. However, if the policyholder needs reconstructive procedures due to an accident, injury or certain medical conditions, it can be covered based on your policy terms.

Hazardous or Adventure Sports (Code: Excl 09)

One of the most common health insurance exclusions may include expenses arising from injuries while you are participating in specified hazardous or adventure sports. These activities generally include mountaineering, rock climbing or similar high-risk activities, depending on the policy's terms and conditions.

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

When talking about medical insurance exclusions, 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 for every policyholder. However, this does not apply to emergency treatments following an accident.
2. 24-month Exclusion for Health Insurance: Many policies implement a specific 24-month 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.
4. Maternity Waiting Period: Pregnancy and childbirth-related expenses will be subject to a waiting period of 9 to 24 months.
5. Critical Illness Waiting Period: Upon the diagnosis of chronic conditions, such as cancer, policyholders have to serve a 90-day waiting period before claiming the lump-sum amount.

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.
5. Behavioural and Neurodevelopmental Disorders: Adult personality disorders and speech and language disorders such as stammering and dyslexia cannot simply be excluded.
6. Puberty and Menopause-Related Disorders: It generally includes treatment for illnesses, symptoms or complications associated with physiological conditions related to puberty and menopause.

Why Must You Disclose Everything While Buying Health Insurance?

When buying insurance, it is important to be completely open and honest. Failure to declare your pre-existing condition can be grounds for rejection of a claim based upon 'Non-disclosure of Material Facts'.

Being honest about your condition will enable the insurers to pay out on it either after a certain period or by charging a small premium loading. A claim can and most likely would be rejected outright without full prior disclosure at times of great need.

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.