There may be various reasons why an insurance company may reject your claim. Sometimes this rejection is valid since such a claim is specifically excluded in the policy document.
While these exclusions vary from company to company, based on our experience of dealing with consumer complaints, we have prepared an extensive checklist of some basic exclusion that most consumers get caught on.
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So before you buy your policy, make sure you check for the following things:
• Pre existing diseases at the time of buying the policy are generally excluded. Many companies do have specific waiting periods after which pre-existing diseases do get covered provided the policy renewals have been continuous and without any break. Make sure you disclose what you already know. This is the single biggest problem in medical insurance claims.
• Certain diseases will be excluded in the first year of the policy. The expenses on the treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hernia, Hydrocele, Congenital Internal Disease, Fistula in anus, Piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout and Rheumatism, Calculus diseases, Joint replacement due to Degenerative Condition and age related Osteoarthritis and Osteoporosis are generally not payable until a specific period of time, which differs from company to company. The specific diseases may also differ with the company.
• Treatment for Injuries or diseases directly or indirectly arising from invasion of a foreign enemy, or due to war like operations, will not be payable by the health insurance company.
• Expenses on any disease or injury incurred during first 30 days from commencement of the policy are excluded. This clause, however, is not applicable on renewal of the policy. Also, in case of an accident, you will be covered.
• Cosmetic surgeries, cost of spectacles, cost of dental treatment are generally excluded from Mediclaim. Treatments other than allopathic (i.e. homeopathy, ayurvedic, naturopathy) are also excluded.
• Expenses on vitamins and tonics that do not form a part of treatment for injury or disease; will not be paid by the health insurance company.
• Any kind of service charge, surcharge, admission fees or registration charges levied by the hospital is not reimbursed under your health insurance policy.
• For the most part of Dental Care, Hearing and Vision care are not covered as these do not require hospitalization, and in India, health insurance is mainly associated with the charges for treatment in a hospital. So unless, hospitalization is required, these are not payable.
• Expenses arising from treatment of HIV+ or AIDS are usually excluded. This is very important. Check this clause with your insurer.
• Medical expenses arising from misuse of liquor, drugs etc is also not included in the health insurance policy.
The basic idea behind this list is to ensure that every policy-holder is aware of such exclusions that are a part of standard industry practice and enable them to ask the right questions. In the long run, asking the right questions is sometimes the best way to avoid unwanted, unnecessary hassles.
Suresh Kumar Narula is founder and Principal Financial Planner at Prudent Financial Planners. He has earned the professional CERITIFIED FINANCIAL PLANNER and got registered with SEBI as Investment Advisor. He writes on personal and financial planning articles and got published in Dainik Bhaskar, Business Bhaskar and The Financial Planner’s Guild, India. He is also a member of Financial Planner’s Guild India ( An association of practicing SEBI registered Investment advisers) to create awareness about Financial Planning in general public, promote professional excellence and ensure high quality practice standards. Suresh received his an M.com from Himachal Pardesh University and an MFC from Punjab University, Chandigarh. He can be reached at info@prudentfp.in