Categorized | Health Insurance

critical illness plan exclusions

There are Health Insurance plans that offer protection against critical illnesses so that the Insured person is able to meet the expenses required to cure the disease and cover the loss of regular income because of the illness. Only some diseases are placed under the Critical Illness category. There are Riders associated with the critical illness health insurance plans. The plans also have certain Exclusions that differ from one Mediclaim Policy to another. 
Before one settles for a suitable critical illness health insurance plan, one must check out the conditions for claiming the benefits of a policy. It is important to know the time when one was diagnosed of the illness, duration and severity of the disease, and type of disease that one got. These factors would distinguish the exclusions in the health claims. 

Let’s find out the exclusions of the typical critical illness plan and some essential conditions that must be met to get the benefits.

Common Exclusions

Time Factor
A 90-day Waiting Period is a must from the start of the health insurance policy to avail the benefits. Health claims done prior to this time limit would be considered invalid.

A disease incurred during war or act of war – such as in naval, military or air force operation, diving, gambling, racing, and flight mishaps would not be valid for reimbursement. The exemption would also be applicable if the Policyholder pursues dangerous pastimes, such as parachuting or hang-gliding, trekking and similar adventurous activities. Others in the list of exclusions are:
  • A criminal act or unlawful action
  • Self-inflicting injury or suicide
  • Actions during insanity
  • Intentional self injury or attempted suicide while being sane or insane 
  • Drug abuse 
  • Venereal disease
  • AIDS or sexually transmitted diseases
  • Pregnancy related complications, such as abortion, miscarriage, child birth 
  • Congenital diseases or defects
  • Radioactive radiation
Pre-Existing Condition
Pre-existing conditions would not be included in the health insurance policy. The Beneficiary must survive the diagnosed disease for at least one month prior to the Reimbursement of the benefits. For some insurance policies, there is hospital-cash cover where 2 year waiting period is required. 

Women-Specific Health Plan Exclusions
Exclusion in a women-specific insurance policy would not only include omissions applicable for a general health insurance plan but also exclude other options, such as:
  • Breast cancer, such as pre-malignant tumors, breast lumps
  • Cervical, ovarian, vaginal, multi-trauma and burns
  • Congenital diseases of the child – if the child birth is after the age of 40 years
What to be Cautious About?
Often, expenses incurred from critical illnesses, such as Alzheimer disease, cancer, heart ailments, and stroke are not reimbursed for some policyholders. This is because the causes for getting the diseases are not deemed fit for compensation. Health claims on critical illness diseases got through smoking, alcohol abuse or tensed lifestyle would not be granted. 

There are health insurance plans where the sum Assured is a huge amount.  Premiums are also high. These plans would include some extremely serious critical illness diseases, such as organ transplant. There may also be critical illness riders in health plans that include some of the generally excluded items. 

In general, all health insurance plans have different levels of Coverage and list of exclusions. Although some exclusion is by-and-large common for all health policies, some may cover more diseases depending on the Premium paid by the policyholder.