EXCLUSION and sub-limits in a health insurance policy typically form the bone of contention between a health insurer and the insured. The best way to deal with the situation is to carefully go through the policy document when it arrives and not when your claim is rejected. Being aware of what your policy does not cover is as important as knowing what it does. Increasingly, insurers are also imposing limits on room rent and operation theatre charges, even if the total claim is within the extent of coverage. Therefore, it is critical to understand at least three clauses (pre-existing illness being the third) in your health policy.
Exclusions: This refers to any illness, condition or expense that is spelt out in the policy as being specifically out of the scope of coverage. For instance, most policies do not entertain claims during the first 30 days from policy inception, barring the ones that are accident related. Preventive care, vitamins and tonics and the cost of pacemakers and wheel-chairs are usually not reimbursed.
The same holds true for expenses concerning maternity, dental treatment, outpatient department (OPD) and diagnostic tests (that are not linked to hospitalisation). There are, however, some policies that extend cover to some of these expenses. Amongst ailments, cataract and piles are not covered in the first year. However, if the insured has to undergo medical tests in connection with an upcoming surgery, the same will be covered and so will be the medicines administered during the period. These could be claimed separately as pre-hospitalisation expenses. A majority of health policies cover expenses up to 30 days prior to hospitalisation and 60 days after discharge.
Sub-limits: Many believe that sub-limits are applicable to room rent alone, which is not the case. All other charges, too, are reduced in proportion to the room rent cap. This is primarily because the charge structures levied by hospitals varies as per the type of room chosen by you. This apart, the claim that is finally disbursed to you could be in great variance to what you have estimated, due to another clause: reasonability. If the insurer is of the opinion that you have paid say 1 lakh for a treatment that generally costs 80,000, only the latter amount will be sanctioned.
