Coverage Of Individual Health Insurance Scheme And Exclusions Of Claim
Coverage Of Individual Health Insurance Scheme And Exclusions Of Claim.Medical insurance is a basic financial security instrument that helps a person get financial reimbursement for costs that arise from sickness or accident. An individual health insurance policy avails an individual’s health risks to ensure that one does not spend all their money on a medical bill when they are sick. Read below to find out what individual health insurance schemes offer, and some of the things that they don’t – or, that policyholders should be aware of.
Coverage Offered by Individual Health Insurance Schemes
There are many features that one can include in an individual health insurance plan as most of medical costs are covered subject to the policy. Here’s an overview of the key coverages provided:Here’s an overview of the key coverages provided:
1. **Hospitalization Expenses**
In most of the health insurance offerings out there, hospitalisation is considered to be the main value proposition. This refers to the cost incurred on treatment while the patient is admitted in the hospital and stays for over 24 hours. This comprises of the rent for the room, nursing fees, the fees of the doctor and the bills for the medical procedures done. It also incorporates surgeries, medical tests, medications among other treatments that are inpatient costs.
2. **Pre and Post-Hospitalization**
Most of the individual health insurance policies base include the expenses of hospitalization and initial medical costs and subsequent medical costs after the hospitalization. This costs include the diagnostic tests and medicines the patient had before admission up to the 30th day before the admission in the hospital. This also entails the charges for follow up consultations and treatments, and other prescriptions up to 60 days after discharge has been given.
3. **Daycare Procedures**
Due to the recent enhancing medical technologies; many treatments do not necessitate a long stay in the hospital. Outpatient processes are those processes of treatment or surgeries which can be done in a day and do not require the patient to stay in the hospital for more than 24 hours. These procedures include cataract surgery, chemotherapy, dialysis and all other minor surgeries and these are provided under the health insurance policies.
4. **Domiciliary Hospitalization**
In certain circumstances, a patient can be too sick to be transferred to a hospital, and health care is rendered to him at home. This is also known as domiciliary hospitalization and most health insurance policies may cover such treatments depending on such factors like need for treatment and the period that the treatment will take.
5. **Ambulance Charges**
Some OGHS include ambulance expenses because they finance the transport of the insured person to the hospital when he, or she is in a critical condition. Other medical expenses, such as the air ambulance also form part of the covered expenses though the amount to be reimbursed may be limited.
 6. **AYUSH Treatment**
Most of the new insurance policies contain provision for treatments under other systems such as Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH). These are legal systems of medicine in India and inclusion of these into the health insurance policy underpins the increasing integration of the whole person approach to the treatment.
7. **Organ Donation**
Organ donation costs may be covered by the insurance company for the health insurance policies that a person has as well as the costs of the surgery to extract the organ. However, the incurred medical cost of the donor may not be reimbursed and this benefit is usually restricted on the type of disease as determined by the insurer.
8. **Mental Health Treatment**
Mental health is one of the focuses of attention in today’s society, and, therefore, insurance policies include the costs in the case of mental disorders. This is inclusive of the therapy expenses in one’s mental health, the medication cost, and even the expenses in hospitalization owing to mental related issues.
 9. **Maternity and Newborn Cover**
Self employed health insurance plans also provide benefit for maternity health expenses such as prenatal and postnatal care costs, delivery expenses and even baby expenses. But such coverage will not be available immediately and may take as long as 2 to 4 years before one can get reimbursed for it.
10. **Preventive Health Checkups**
Most insurance companies provide free annual health checkups which help the policy holders to check regularly on their health. This is normally offered after a specified number of years without making any claims and it is considered as a method of encouraging health check-ups and early diagnosis of such related complications.
Coverage Of Individual Health Insurance Scheme And Exclusions Of Claim
Common Exclusions in Health Insurance Policies
As much as individual health insurance encompasses almost every medical expense, there are some limitations that popularly exist in almost all insurance polices. Knowing about these exclusions is very important as this may come as a shocker when it comes to the actual point of paying for the claims.
1. **Pre-existing Diseases**
Excluded illnesses are those diseases or illnesses that the policy holder contracted before they took the health insurance policy. These are normally not covered for a particular period of time, which ranges from two to four years. However, after this waiting period, most of the insurers treat the pre-existing conditions and complications if none was encountered during this waiting period.
2. **Cosmetic and Aesthetic Procedures**
Cosmetic surgery or if the surgery is done for beautification purposes or if it is considered as an elective surgery; it will not be covered. This includes cases such as; Liposuction, botox, rhinoplasty and other related treatments unless they are required due to an accident or an illness that required body reconstruction.
3. **Dental Treatment**
Conditions such as cavities and fillings, simple tooth removal, root canal, braces and other orthopedic dental work are considered excluded unless an accident caused them. Sometimes the policies may include dental cover, but this is usually done through a rider, which attracts an extra cost.
4. **Fertility Treatment**
A lot of insurance policies which cover health has excluded fertility treatments such as IVF, IUI among other fertility treatments. It is also important to note that some of the insurers may include these treatments as extra options.
5. **Self-Inflicted Injuries**
Self-inflicted injuries, suicide attempts or any kind of post-suicide injuries do not qualify for being paid by health insurance policies. This exclusion which is provided in the policy excludes non-accidental injuries hence ensuring insurance is not abused.
6. **Falls Due to Alcohol or Drug Use**
Any charges that result from injuries or illnesses that were as a result of alcohol or drug related incidences cannot be paid through an health insurance. This comprises of sicknesses, injuries and any other unfavorable consequences which arise from substance use.
7. **Participation in Hazardous Activities**
Policies involing either the medical aid insurance or the health insurance have preclusions that would disallow coverage’s for any injuries resultant from hazardous or adventure activities such as; skydiving, scuba diviving, bungee jumping or professional sporting or similar events. While some of the insurers may provide extra options for cover for such activities, it is normally not included in the policies.
8. **War and Terrorism**
Such injuries or sicknesses that arise from war or terrorism, nuclear hazards or other catastrophes often are not compensated. Such activities are usually accompanied by the following disclaimer that is usually contained in any policy; ‘This policy does not cover any claim resulting from the said activities.
9. **General Wait Time For Particular Diseases**
Some ailments include cataracts, hernia, or even the knee replacement surgery which take about 1 to 2 years of cover to be supported by the health insurance. Thus, during this period such diseases will be excluded and claims under this policy will not be entertained.
10. **Non-allopathic Treatments**
While a lot of existing policies have incorporated AYUSH, and naturopathy Acupuncture and other systems of treatments that fall under the sections 42 imply that treatments like acupuncture and other forms of medicine that are different from the allopathic type will not be covered unless mentioned. If you are particular with the kind of treatments your insurance company offers, it is also wise to look at the policy terms.
Conclusion
With the individual health insurance policy, it is important for those policyholders to know what is covered and what is excluded from the plan to have maximum benefits from the plan and not to end up having a rejected claim. While it is inclusive and covers most forms of treatments and forms of expenditures on medical bills, the policy has some wastage areas that the buyer should consider before purchasing the policy. It is equally prudent to read the policy document and where possible consult the insurer on unclear terms with the view of choosing a health plan that responds effectively to one’s health needs.