What Critical Illness Insurance Does Not Cover​

What Critical Illness Insurance Does Not Cover

Published on January 18, 2024

Need help raising funds for medical emergency?

While regular health insurance covers the basics of doctor visits and hospital bills, critical illness insurance steps in when faced with severe illnesses like cancer or a heart attack. Critical illness insurance serves as a financial superhero during major health crises, easing the burden so you can focus on recovery without financial stress.

It’s not a replacement for regular health insurance but a vital extra shield, particularly crucial in India, offering essential financial protection during serious illnesses and proving invaluable for those with a family history of critical health conditions. However, like any safety net, there are limits—these are called “exclusions.” Let’s explore some of the exclusions in a critical illness plan.

If you had a medical condition before obtaining the insurance, and it’s related to the critical illness you’re claiming, coverage might be denied. Insurers aim to provide coverage for unexpected situations rather than those already present.

For example, if you had a heart issue and then purchased the insurance, claims for heart-related problems might not be covered. To know more about existing diseases allowed to be permanently excluded visit the IRDAI website.

Some policies have a waiting period after purchase, typically 60 days (sometimes 30 days), after the policy is purchased during which no claims can be made. If you fall ill during this waiting period, the insurance might not cover it.

Sexually transmitted diseases, including AIDS and the presence of HIV, are commonly excluded. Insurance policies generally focus on diseases that are not a result of lifestyle choices.

If, unfortunately, the policyholder passes away within 30 days of the diagnosis of a critical illness or after undergoing surgery covered by the policy, the insurance may not be applicable. This provision is in place to prevent misuse and ensure genuine claims.

Health issues present from birth (congenital conditions) are generally excluded. Policies are designed to address unforeseen health challenges that may arise during the coverage period.

While critical illness insurance is designed to provide financial support during severe health crises, dental procedures, including those associated with oral cancer, are commonly exempted. Policyholders should be aware that critical illness insurance may not extend to cover the comprehensive range of treatments specific to dental health, emphasizing the importance of supplementary dental insurance or stand alone dental coverage for comprehensive oral care.

Also teeth cleaning, fillings, root canals, and braces are a few dental procedures that are quite common. These procedures use advanced dental equipment which is quite expensive. The dental chair alone costs somewhere around Rs 90,000 to 1.5 lakh. The total cost including the other tools and equipment could go as high as Rs 10 lakh. Hence, dental treatments are very costly.

Coverage is often denied in cases of self-inflicted injuries, suicide attempts, insanity, or participation in illegal or criminal activities. Insurers aim to discourage intentional harm

If your critical illness is linked to alcohol or drug abuse, the insurance might not cover it. Policies prioritize situations where the illness is not a result of substance abuse.

Critical Illness Insurance is designed to address health concerns, not those arising from external events like foreign invasions. Instances related to war and external conflicts may not fall under the purview of the insurance coverage.

Engaging in extremely dangerous activities, like extreme sports, might lead to denied claims if illness arises from these activities. The expectation is that policyholders exercise reasonable care to safeguard their health. Hence, policies intend to cover illnesses unrelated to risky behaviors.

Occupational hazards associated with working in underground mines or tunneling are often excluded. If a critical illness stems from these high-risk occupations, the insurance may not provide coverage. This underlines the importance of assessing occupational risks.

Illness resulting from radioactive contamination due to a nuclear accident is generally excluded. This exclusion aligns with the complex, unpredictable and high-risk nature of such events.

If an individual neglects to seek or follow medical advice, leading to the worsening of a condition, coverage may be denied. This exclusion emphasizes the importance of timely medical attention.

Opting for experimental treatments not widely accepted in the medical community might not be covered by your insurance. It’s essential to discuss treatment options with your healthcare provider and insurer to ensure alignment with policy coverage.

Treatment for a donor involved in organ replacement procedures is usually not covered. The primary focus is on providing coverage for the person insured against critical illnesses.

Hormone replacement therapy, addressing conditions like menopause, ART, and transgender hormone therapy, can be expensive. The drug cost alone is approximately Rs 50,000 to Rs 60,000 per month, making the entire treatment even more costly, as reported by The Financial Express

Other than these standard health insurance exclusions, sometimes, the use of hospital phones, TV, or extra pillows during hospitalization comes under standard exclusions in health insurance policies.

Understanding these exclusions is crucial when considering a critical illness insurance policy. It’s recommended to thoroughly review policy documents, ask questions, and seek clarification to ensure comprehensive coverage that aligns with individual health situations and lifestyle choices. Remember, the goal is not just to purchase insurance but to ensure it provides the necessary protection when it matters the most.

However, in cases where Critical Illness Insurance falls short due to exclusions, it’s worth exploring alternative avenues. Medical Crowdfunding has emerged as a powerful tool, providing a community-driven solution to financial challenges during health crises. It has proven to be a lifeline for thousands of people especially during the pandemic when the unemployment rate rose to 7.5% in the first three months in India.

Medical crowdfunding allows individuals to share their stories, garner support, and receive financial assistance from a network of caring individuals.

Remember, Milaap is always there to help you in case these health insurance exclusions leave you facing unexpected financial burdens.

Please note: This information is for general purposes only and is not financial or legal advice.

The details presented are subject to change due to various factors, such as regulatory updates, economic conditions, and individual circumstances. Relying on this information is at the reader’s own risk, and it is advisable to consult with financial experts for accurate and up-to-date information tailored to individual circumstances.

In times of need, support means everything, and with Milaap, you need not look any further. Milaap enables you to set up a fundraiser for any medical emergency within minutes, and you can easily raise funds for treatment expenses.

Do you know someone who could benefit from fundraising? Simply refer them to us and we’ll be happy to lend a hand.

Visit www.milaap.org or call us on +91 9916174848 to get started now.

For more information, write to us at cx@milaap.org.