Permanent Exclusions in Health Insurance: Complete List as per IRDAI
Permanent exclusions in health insurance are conditions, treatments, or circumstances that your insurer will never cover, regardless of how long you've held the policy. Unlike waiting period exclusions that lift after a certain time, these are written into the policy permanently and do not change at renewal. Understanding what to check in health insurance coverage is crucial, as knowing the exclusions can help you avoid disappointment when you need your coverage the most.
What are the most common health insurance exclusions and limitations?
IRDAI has standardised a base list of exclusions that every insurer must follow. Individual insurers can add further exclusions depending on the plan. The fifteen most common permanent exclusions in health insurance policies are listed below.
1. Pre-existing diseases disclosed at inception
Coverage for Pre-existing diseases (PEDs) is typically offered after a waiting period of 1 to 3 years. However, if a person deliberately hides information regarding any PED during the purchase of insurance, the insurance company has the right to completely exclude that disease from coverage or even terminate the insurance contract itself.
2. Cosmetic and aesthetic treatments
Any procedure carried out solely for enhancing your physical appearance is automatically excluded from coverage forever. For example, nose correction, liposuction, breast augmentation, hair transplant, Botox, etc., belong to such a list. But if any surgical operation is performed due to an injury or because of necessity, such as an appendectomy, then there may still be chances of insurance coverage.
3. Self-inflicted wounds
Injuries and diseases resulting from self-inflicted wounds will remain permanently excluded from the insurance plan. This includes any attempt at suicide or the infliction of physical injury on oneself. The reason behind this is quite simple, as insurance is meant to cater to the unexpected.
4. Acts of war, terror, and radiation
If one suffers any form of illness due to war (declared or undeclared), civil disturbances, acts of terrorism, or even exposure to nuclear, chemical, and biological warfare, it would be permanently excluded from coverage by health insurance.
5. Infertility & reproductive techniques
All treatments connected to infertility, such as IVF, IUI, Surrogacy, etc., will never be covered under any insurance policy. Few new insurance plans offer options of infertility coverage as additional benefits, but it is not included in any plan by default.
6. Experimental treatments
Experimental treatments, which have not been acknowledged by the mainstream medical community, and those that fall into the unproven category or experimental category, will be excluded from coverage under the insurance scheme. This includes treatments such as stem cell therapy in cases where it is not yet proven.
7. Genetic disorders & congenital issues
Generally, all congenital problems as well as hereditary genetic disorders are excluded for life by the health insurance companies. This exclusion is applicable to internal and external congenital deformities unless otherwise stated in the specialised scheme.
8. STDs
Diseases like syphilis, gonorrhoea, and genital herpes come under the head of permanent exclusions. HIV/AIDs treatments were earlier considered as a permanent exclusion, but now IRDAI has made it mandatory for insurers to cover them since 2018.
9. Obesity and weight loss programmes
Obesity treatment programmes, surgeries, and weight-loss diets are completely excluded except when there is a medical necessity for such procedures due to an existing health problem. Insurers categorise obesity as a lifestyle choice rather than an ailment warranting hospitalisation coverage.
10. Dentistry procedures
All dental treatments, which include tooth fillings, root canal procedures, tooth extraction, teeth whitening, orthodontic braces, and dentures, are totally excluded. Coverage will only be considered for dentistry procedures if there is an accident or if there is a surgical hospitalisation requirement.
11. Vision correction
Corrective procedures such as LASIK surgery, spectacles, and contact lenses are excluded from standard health insurance plans. Vision deterioration due to age or refractive errors is not considered a medical condition under these policies. Cover for eyewear is occasionally available as an OPD add-on.
12. Substance abuse and addiction
All expenses related to alcoholism or drug dependence are permanently exempt from insurance coverage. This also includes detoxification treatment programmes.
13. Pregnancy & maternity (For most standard plans)
Health insurance plans provided to individuals do not include payments for any expenses pertaining to pregnancy. Expenses during pre- and post-pregnancy, deliveries (both natural and Caesarean), etc., will be excluded unless a rider has been purchased for this benefit.
14. Hazardous sports & adventurous sports
Injuries caused by participation in hazardous or adventurous sports such as sky diving, motor racing, rock climbing, etc., are permanently excluded from coverage. In case you take part in hazardous sports or adventurous sports on a regular basis, you will require a special insurer for that purpose.
15. Treatments outside the scope of modern medicine (Unless specified)
While AYUSH (Ayurveda, Yoga, Unani, Siddha, Homoeopathy) has been mandated for inclusion by IRDAI in many standard plans, fringe or unrecognised systems of treatment that fall outside approved medical practice remain excluded.
Conclusion
Exclusions under the health insurance cover are always permanent and apply to all policies without exception. The only way to avoid these exclusions is to buy a health insurance policy with great care, reading the policy wording carefully, and especially the exclusions clause. Where an individual suffers from certain diseases or displays behaviours that bring about certain exclusions, then one should consider looking for a health insurance policy that can cater to their needs.
Frequently asked questions
How do permanent exclusions differ from waiting period exclusions in health insurance?
Waiting-period exclusion is temporary and applies for a fixed duration (usually 30 days to 4 years). Once the period is over, the condition gets covered. On the other hand, permanent exclusions are not covered under the policy, regardless of how long you've been a policyholder. Pre-existing diseases come under waiting period exclusions; cosmetic surgery and self-inflicted injuries are examples of permanent exclusions.
Is a cosmetic/aesthetic procedure exempt from health insurance forever?
No health insurance policy in India covers cosmetic surgery procedures. Any procedure involving any kind of medical procedure done just to enhance one's beauty is not covered by any kind of health insurance policy.
What is the meaning of standard exclusions in health insurance policies?
Standard exclusions in health insurance policies refer to a list of exclusions which IRDAI mandates that all insurers should exclude. Self-inflicted injuries, congenital conditions, infertility treatments, cosmetic surgery, treatment of tooth decay or visual impairment, and injuries due to risky behaviour are included under this.
What is the role of IRDAI in the definition of standard exclusions in health insurance?
IRDAI is a regulating authority for insurance in India. It mandates a list of exclusion clauses in the insurance policy document which are applicable to all insurers. Recently, IRDAI has made some changes in the list of exclusion clauses, such as covering the medical costs related to the treatment of HIV/AIDS and AYUSH treatments.
Which treatments are commonly included as permanent exclusions?
Procedures like cosmetic surgery, treatment for infertility, treatment related to drug abuse, any harm caused to oneself intentionally, experimental treatments, obesity, any dental problems and treatment resulting from war, terrorism, and hazardous activities are common in health insurance. Genetic diseases are also common types of exclusions, especially for older health insurance policies.
Disclaimer: The information shared in this blog is intended solely for general awareness and should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare provider for personalised recommendations and care.
