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What Does Health Insurance Not Cover?

Certain conditions are not covered under health care plans. It is essential to know the exclusions under healthcare insurance to be prepared for emergencies.

  • 3,448 Views | Updated on: Dec 26, 2023

Healthcare insurance is a critical aspect of managing and safeguarding your health and well-being. With the rising costs of medical care, having a comprehensive understanding of healthcare insurance is essential for individuals and families alike.

Key Takeaways

  • Health insurance plans provide financial protection against medical expenses, offering peace of mind and access to quality healthcare.
  • Indemnity plans cover hospitalization expenses, while defined-benefit plans provide a lump sum for critical illnesses, accidents, or hospitalization.
  • Carefully assess your healthcare needs, budget, and preferred providers when choosing a plan.
  • Understand exclusions such as pre-existing conditions, pregnancy, and cosmetic procedures to avoid surprises.
  • Maximize your coverage by understanding covered services, benefits, and network of providers.

Health insurance plans give financial respite during critical illness, abrupt surgery, or a medical emergency. Health insurance plans from different service providers vary in the coverage, benefits, and riders offered. As an alert policy buyer, you should understand the offerings and the exclusions of the health insurance plans to avoid misinformation.

Understanding Healthcare Insurance

Healthcare insurance is like having a reliable companion for your medical expenses. It is a contract between you and an insurance company that helps cover the cost of your healthcare services. In exchange for paying a monthly premium, the insurance company helps foot the bill when you need medical care, whether it is a routine check-up or a more serious procedure.

Medical expenses can quickly spiral out of control, leaving you with a hefty bill that could take years to pay off. Healthcare insurance provides a safety net, ensuring that you can access the care you need without breaking the bank. It also offers peace of mind, knowing that you will not be left high and dry if an unexpected health issue comes your way.

Types of Healthcare Insurance Coverage

There are two main types of healthcare insurance coverage in India:

  • Indemnity plans
  • Defined-benefit plans

Indemnity Plans

Indemnity plans are the traditional health insurance that covers your hospitalization expenses up to the sum insured. These plans include:

Mediclaim Insurance

Mediclaim insurance is a type of health insurance policy that provides coverage for medical expenses incurred due to hospitalization. It covers a wide range of medical expenses, including hospital room charges, doctor’s fees, surgery costs, and diagnostic tests. Mediclaim insurance is available from a variety of insurance companies in India.

Individual Coverage

Individual insurance is like shopping for the perfect pair of jeans – you get to choose what works best for you. If you do not have access to employer-sponsored insurance, you can purchase an individual plan directly from an insurance company. These plans come in different flavors, allowing you to select one that fits your needs and budget.

Family Floater Plan

A family floater plan is a type of mediclaim insurance policy that covers all members of a family under a single policy. This means that all family members can avail of the benefits of the policy, regardless of who is hospitalized. Family floater plans are a more cost-effective option for families with multiple members. It offers flexible sum insured options, which means that you can choose the sum insured that best suits your needs and budget.

Senior Citizen Coverage

Senior citizen health insurance plans are meant for senior citizens aged 60 years or above. These plans offer additional benefits that are tailored to the needs of senior citizens, such as coverage for age-related illnesses and pre-existing conditions. These plans offer higher sum insured options, as senior citizens are more likely to incur higher medical expenses.

Defined-benefit Plans

On the other hand, under a defined-benefit plan, the insured is compensated a lump sum amount on the detection of illness. These plans include:

Critical Illness Plan

A critical illness plan covers you for a specified list of critical illnesses. It is designed to provide financial support in the event that the insured person is diagnosed with a critical illness specified in the policy. It covers serious medical conditions such as cancer, stroke, heart attack, organ transplantation, and certain types of surgeries. The policy pays out a lump sum benefit upon the diagnosis of a covered critical illness. The lump sum payout from the critical illness plan can be used to cover medical expenses, loss of income during treatment, rehabilitation costs, or any other financial obligations that may arise due to the critical illness.

Personal Accident Plan

A personal accident plan covers you for accidental injuries. It covers accidental death, dismemberment, or disability resulting from accidents. Some policies also provide coverage for medical expenses incurred due to accidents. This plan typically pays out a lump sum benefit for accidental death or dismemberment. The benefit may vary based on the severity of the injury. The policy can provide financial assistance for medical expenses, rehabilitation costs, lost income due to disability, or a lump sum payment to the beneficiary in case of accidental death.

Hospitalization Cash Benefit Plan

A hospitalization cash benefit plan is like a safety net that can help you cover the extra costs you might have when you are in the hospital. It does not matter what kind of illness or accident you have; as long as you are hospitalized for at least 24 hours, you will get a fixed amount of money each day you are there. This money can be used for anything you need, like paying for food, transportation, or even your rent or mortgage.

Exclusions Under Healthcare Insurance

Though for the sake of uniformity, the Insurance Regulatory and Development Authority of India (IRDAI) has standardized health insurance plan exclusions, ask your insurance agent to inform you about things that are usually not covered in health insurance benefits.

Here is a list of six aspects excluded from a health insurance plan:

Pre-existing Diseases

Already existing diseases are generally not covered in a new medical insurance plan. Some service providers may include pre-existing diseases like diabetes or high blood pressure, but only after the waiting period is over, which could typically range between 2-5 years. Some of the health insurers may cover pre-existing diseases at the cost of an extra premium.

Pregnancy & Miscarriages

Pregnancy and miscarriages are not a part of health insurance plans. The charges meted for pre-natal, cesarean surgery, or post-natal care are to be borne separately by the policyholder. Abortion is also generally excluded until it is involuntary and crucial for the survival of the mother. If needed, the case is presented to the insurance company under the reference of the certified medical team. However, some plans give coverage to maternity benefits subject to conditions.

Supplements & Stimulants

The cost of health supplements and stimulants does not fall under health insurance plans that are not part of the doctor’s recommendation for combating any covered disease. A health insurance plan covers only those tonics and supplements that the treating doctor prescribes.

Cosmetic Surgery

Though cosmetic surgeries like injecting botox, liposuction, etc., have become very common these days, they are not yet part of any medical insurance plan. They are generally expensive and taken voluntarily for enhancement of looks. Still, if the treating medical practitioner recommends the need for cosmetic surgery in critical accident cases, a health insurance plan may cover it, subject to their conditions.

Dental Procedures

Dental procedures are excluded from health insurance plans, especially if they are for cosmetic enhancement. However, suppose dental treatment is part of some critical surgery and crucial for a patient’s life. In that case, your insurer might consider it on the doctor’s recommendation and under relevant terms and conditions.

Non-Medical Miscellaneous Charges

Hospitalization involves many non-medical expenditures ranging from registration fees, admission charges, ambulance charges, service charges, etc. These are unavoidable and still not covered in health insurance policies.

What Does Health Insurance Cover?

Health insurance can cover a wide range of medical expenses, depending on the specific plan you choose. Here are some of the most common types of expenses that are under health insurance coverage:


This includes the cost of your hospital room, board, and nursing care. It may also include the cost of laboratory tests, X-rays, and other diagnostic procedures.

Doctor Visits

This incorporates the cost of seeing a doctor for preventive care, checkups, and treatment of illnesses and injuries.

Prescription Drugs

This includes the cost of prescription medications that a doctor prescribes.


The cost of surgery, as well as the cost of anesthesia, hospital rooms, and other related expenses, are covered under healthcare plans.

Preventive Care

Preventive care covers the cost of vaccinations, screenings, and other preventive measures that can help to keep you healthy.

Making the Most of Your Healthcare Insurance Coverage

While buying a plan, it is up to you to make the most of it by availing of the advantages of the plan. Here are some tips to get the most out of your health plan:

Understanding Covered Services and Benefits

Covered services and benefits are like little perks hiding within your insurance plan. They include things like doctor visits, hospital stays, and prescription drugs that your plan will help pay for. So, familiarize yourself with your plan’s list of covered services and benefits and start using them like a pro.

Utilizing Preventive Care Services

Preventive care services are like the superheroes of the healthcare world, swooping in to save the day before things get messy. These services include things like vaccinations, screenings, and check-ups that can help catch potential health issues early on. It is like having a personal health detective looking out for you. So, do not forget to take advantage of these preventive care services.

Maximizing the Use of Network Providers

Network providers are healthcare professionals who have partnered with your insurance company to provide you with discounted rates for their services. This arrangement offers you the benefits of being part of an exclusive network of preferred providers. It is akin to being a valued member of an elite club where you receive preferential treatment. Therefore, it is crucial to check if your preferred healthcare providers are included in the network to reap the full advantages of being part of this select group.

Common Challenges and Solutions in Healthcare Insurance

Along with the advantages of coverage and other benefits, there are also some challenges that one might face with healthcare plans. Let us have a look at those challenges and solutions:

Dealing with Claim Denials or Disputes

Claim denials or disputes are the equivalent of a raincloud on your parade. You have received healthcare services, submitted the claim, and then bam! Denied. But there are ways to fight these denials. Start by reviewing your insurance policy and understanding why the claim was denied. Then, gather any necessary documentation or evidence to support your case.

Navigating the Appeals Process

The appeals process is a way to challenge a denial of coverage or reimbursement for a healthcare service by your insurance company. It can be a confusing and frustrating process, but it is important to know that you have rights and options if your claim is denied. Your chances of success with an appeal will vary depending on the specific circumstances of your case. However, if you have a strong case and you present it effectively, you have a good chance of getting the decision reversed.

Addressing Changes in Coverage and Plan Options

Healthcare insurance plays a crucial role in our lives, providing financial protection and access to necessary medical care. By understanding the intricacies of healthcare insurance, from choosing the right plan to navigating the market and maximizing your coverage, you can make informed decisions and effectively manage your healthcare needs. Remember to stay informed about changes in coverage and take advantage of preventive care services to maintain your health.

Way Forward

Understanding healthcare insurance is crucial for navigating the complexities of medical expenses and ensuring access to quality healthcare. Awareness is primary when buying a health insurance plan. If the technical terms of the insurance world are confusing, ask your health insurance agent to list the policy exclusions. They may vary between plans and insurers and thus deserve your close attention and understanding before the purchase. By carefully assessing your needs, comparing plans, and understanding exclusions, you can empower yourself to make informed decisions and safeguard your financial well-being in the face of unexpected health challenges. Remember, healthcare insurance is an investment in your health and peace of mind, providing a safety net that can help you weather any medical storm.

- A Consumer Education Initiative series by Kotak Life

Amit Raje
Written By :
Amit Raje

Amit Raje is an experienced marketer who has worked in various Fintechs and leading Financial companies in India. With focused experience in Digital, Amit has pioneered multiple digital commerce in India. Now, close to two decades later, he is the vice president and head of the D2C business department. He masters the skill of strategic management, also being certified in it from IIMA. He has challenged his challenges and contributed his efforts in this journey of digital transformation.

Amit Raje
Reviewed By :
Prasad Pimple

Prasad Pimple has a decade-long experience in the Life insurance sector and as EVP, Kotak Life heads Digital Business. He is responsible for developing user friendly product journeys, creating consumer awareness and helping consumers in identifying need for life insurance solutions. He has 20+ years of experience in creating and building business verticals across Insurance, Telecom and Banking sectors

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