Permanent exclusions in health insurance & specific illnesses

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For some, trust in insurers is low. But others have an absolute assurance that the leading insurance companies will honour their obligations no matter what happens. However, this isn’t necessarily the case. It doesn’t mean that insurers are dishonest; it’s more likely due to possible misuse of their system.

If you’re diagnosed with a cataract and your doctor recommends surgery in the near future, now is an ideal opportunity to offset all future medical costs by getting health insurance. Since you have the time, why not make this beneficial financial move?

It’s an advantage to have an insurer pay a bill when you’re hospitalised. Even though the premium might be high, it’s still much lower than what you’d pay for surgery – normally over Rs. 50,000. It’s beneficial to you either way, so it really is a great deal.

To ensure their protection from any unexpected scenarios, can insurance companies confidently base their evaluation of accuracy on medical documents alone?

Health insurance providers have another way to protect themselves – by imposing a waiting period for certain illnesses where treatment can be delayed. 

Cataracts, stones, and even operations for deviated nasal septum needn’t be done immediately, so insurers are often able to impose a two year waiting period before allowing any claim related to these conditions.

When presented with the provided list of diseases, many people feel that insurers hardly provide any adequate protection during the first two years. Complaints about the lack of coverage, despite paying the full premium, are common and have become a familiar pattern.

Though this evaluation may appear daunting to someone without a deep knowledge of the field. However, only a fraction of ailments is mentioned.  After 30 days, dengue, malaria, fractures, certain forms of cancer and heart issues are mentioned. They’re not included in the “specific illness” list.

For the initial 30 days, insurers don’t provide payouts for anything apart from accident-related hospital bills. The exact definition of what falls under this category may vary between companies, but usually speaking, incidents such as electrocution or a severe car crash would be covered.

Companies in the insurance business may employ a strategy to limit their responsibility. Other than an exhaustive list of particular illnesses, they would also assign sub-limits when it comes to diseases in general.

Imagine an insurer offering you a remarkable bargain — Rs 10 lakh cover at a premium of Rs 6,000 annually. This price cannot be beaten by anyone else. Despite being sceptical, you decide to go ahead with the purchase since they are a family friend.

One day, reality hits: a slipped disk forces you into the operation theatre. You undergo extensive treatment, leaving you with a hefty bill of Rs 4,36,000 including every cost. Even though you have insurance coverage of up to Rs 10 lakhs, the insurer informs you that they can only reimburse Rs 2,00,000. Outraged by this announcement, you demand an explanation.

At that moment, they quickly inform— There is a limit on the overall coverage amount that has been specifically set aside for particular ailments, commonly known as disease-specific sub-limits.

In the case of cardiovascular diseases, reimbursement is limited to Rs 2,50,000.

The cost of a knee replacement is- Rs 2,75,000

For cataracts — Rs 50,000

In short, you were taken advantage of by buying a policy that provides minimal coverage. You can’t eliminate the risks posed by certain illnesses, but you should be able to find a policy that doesn’t include disease-wise sub-limits. Picking the right policy will be as good as gold.

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