Your health insurance policy will not pay for the treatment of all ailments.
If you have a health insurance policy, you might be aware that it covers certain diseases only after a waiting period of four claim-free years. But do you know that conditions related to genetic disorders are not covered at all? And that claims relating to certain self-inflicted ailments—such as cirrhosis (liver disease) due to excessive intake of alcohol, lung and throat cancer due to tobacco use, and HIV—can also be rejected by an insurance company. All this is explicitly stated in the policy terms and conditions but buyers seldom go through the fine print. Even the agent will not disclose these intricate features of the policy for fear of losing business. An agent will not usually tell the buyer about all the exclusions in the policy.
Congenital diseases
Conditions such as cataract, hernia and sinusitis, which take a few years to develop into a full-blown ailment, are usually covered after a waiting period of 1-2 years. But genetic disorders such as cystic fibrosis, Down's Syndrome, thalassemia and congenital anaemia don't ever get covered. Often a congenital disease is confused with pre-existing diseases, which are covered in most cases after the fourth policy year. If a person is hospitalised due to an illness and it is discovered that it is a congenital disease, the insurance company may deny the claim.
There are instances when a person may never know that he suffers from a genetic defect. "If one has regularly undergone medical checkups but a pre-existing ailment never showed up in the tests, the courts have held that the cost of treatment of such an ailment has to be paid by the insurance company. Insurers too are lenient if they know that it was a genuine oversight. If the patient genuinely mistook an earlier heart attack to be only a chest pain due to indigestion, we will consider the claim.
Self-inflicted ailments
Another reason why a claim can get rejected is if the ailment has been self-inflicted. At the time of application, one has to declare whether he consumes alcohol or uses tobacco. If a person has stated that he is a teetotaller but ends up in hospital with cirrhosis, the claim may be denied. However, there is a fuzzy line of subjectivity here. Insurance companies deny claims for treatment of cirrhosis in such cases under the exclusion self-injury. But they pay for treatment of cancer even for smokers. The logic is that while in nearly 100% cases the cause of cirrhosis is alcoholism, no such empirical relationship exists between cancer and smoking.
Investigative diagnostics
Similarly, investigative diagnostics are not covered by insurance if there is no proof of treatment. There have been cases where doctors are unable to detect a problem and suggest a battery of tests. Later the tests reports revealed that nothing is wrong. The claims were rejected because the hospitalisation was primarily for diagnostic purposes. Even if the hospitalisation and the tests were prescribed by a qualified doctor, the claim will still be rejected. "The tests may have been conducted because a doctor prescribed them but there is nothing to justify payment. The insurer will pay only for curative treatment. Besides, policies reimburse costs incurred after hospitalisation for up to 90 days. Here too, there is the condition that the 90-day period must commence and end within the policy period.
Pregnancy
Though some standalone health insurance companies such as Apollo Munich do cover maternity costs after four years of continuing with the policy, most health policies do not cover these expenses. Even in the case of Apollo, there is a limit to the expenses under this head. Besides, insurers don't cover pregnancy related complications. But there are some exceptions again. Consider the case of a pregnant woman contracting jaundice. Had she not been carrying, jaundice may not have warranted a hospitalisation. But if it were not for the attack of jaundice, the woman might have normally sailed through her pregnancy without any hospitalisation. As such, if it is clinically established that it is jaundice that led to hospitalisation, cost of such hospitalisation will be paid despite the fact that hospitalisation may not have been warranted for treating jaundice had the patient not been pregnant.
Equipment costs
Medical equipment presents its own complications. The cost of prosthetic and other devices or equipment if implanted internally during a surgical procedure are covered. However, the cost of external aids such as ventilators will not be covered. The logic: Ventilation is merely a process helping ease breathing, not an active line of treatment in itself. However, if a patient is undergoing some active line of treatment and as part of it is also put under ventilation (immediately after a surgery), insurance cannot knock of the cost of ventilation from the admissible claim.
