What Is Covered and Not Covered Under Health Insurance?

A hundred questions probably run through your mind before buying a health insurance policy. Will the policy actually pay when you need it the most? What if the hospital bill has some hidden expense the insurer refuses to settle? What if a claim gets rejected after years of paying premiums? These worries are completely normal, and most first-time buyers in India go through the same anxiety before signing up for a plan.

Traditionally, many Indians picked a health insurance policy based on the premium alone, without checking what it actually covers. Some relied on a friend’s recommendation, some picked the cheapest option available, and very few actually read the policy very carefully. Read on to uncover what is covered under health insurance and what is not covered under health insurance in India.

What is covered under health insurance in India?

Every health insurance policy has a list of inclusions that outlines medical expenses the insurer normally pays for.

Health Insurance Inclusions	Description
In-patient Hospitalisation Expenses	Room rent, ICU fees, nursing charges, and doctor fees when you are admitted to the hospital for more than 24 hours.
Pre & Post Hospitalisation Costs	Medical tests, doctor visits, physiotherapy, and other expenses before you enter the hospital and after you leave (often up to 60 days before and 180 days after).
Day-Care Treatments	Advanced medical procedures that require less than a 24-hour hospital stay, such as cataract surgery, dialysis, or chemotherapy.
AYUSH Treatments	Traditional Indian systems of medicine including Ayurveda, Yoga, Unani, Siddha, and Homoeopathy, if done in a recognised hospital.
Ambulance Charges	Coverage up to the policy limit.
Cashless Hospital Network Treatment	No need to pay the entire hospital bill upfront.
Preventive & Annual Health Check-ups	Routine medical tests provided by many insurers.
Maternity & Related Pregnancy Expenses	Covered if your insurer provides it in the plan or as an add-on.
Organ Donor Expenses	Donor-related medical costs during an organ transplant (as per the policy terms and conditions).
Mental Healthcare	Treatment for mental illness, including depression, bipolar disorder, anxiety, or sleep disorders, depending on the insurer's policy and applicable law.
No Claim Bonus (NCB)	Rewards policyholders for claim-free years.
Pre-existing Diseases (After Waiting Period)	Expenses related to pre-existing diseases are covered after a specific waiting period (usually 2 to 4 years).

Note: Health insurance inclusions may vary across insurers, policy types, plan variants, sum insured, and policy terms and conditions. Refer to the policy document for the exact scope of health insurance coverage.

What is not covered under health insurance in India?

Every health insurance policy has a list of exclusions that outlines medical expenses the insurer normally does not pay for.

Health Insurance Exclusions	Description
Pre-existing Diseases (During Waiting Period)	Expenses related to pre-existing diseases are not covered until the specified waiting period ends (usually 2 to 4 years).
Cosmetic Procedures	Plastic surgery or treatments meant to improve appearance rather than treat a medical condition.
Routine Dental Treatment	Cleaning, fillings, cosmetic dental care, and other routine dental procedures.
Weight-loss Surgery	Not covered unless it is medically necessary and specified in the policy.
Maternity & Related Pregnancy Expenses	Not covered unless included in the policy or purchased as an add-on.
Abortion	Not legal in India, hence not covered.
Infertility Treatments	Procedures such as IVF and other fertility treatments are generally not covered.
Congenital Disorders	Medical conditions or abnormalities present at birth, unless specifically covered by the policy.
Self-inflicted Injuries	Injuries resulting from suicide attempts, drug abuse, or excessive alcohol consumption.
Adventure Sports	Injuries sustained while participating in high-risk or hazardous sports such as bungee jumping.
Experimental Treatments	Treatments that are investigational, unproven, or not medically established.
Undisclosed Medical Conditions	Claims related to medical conditions that were hidden or not disclosed while purchasing the policy.
Treatments Outside Policy Terms	Treatments or claims that do not meet the policy's terms, conditions, or eligibility criteria.
Non-medical Expenses	Expenses such as hospital admission fees, cotton, masks, and other general consumables.

Note: Health insurance exclusions may vary across insurers, policy types, plan variants, sum insured, and policy terms and conditions. Refer to the policy document for the complete details.

At this point, you have understood how the ‘buy first, understand later’ approach leads to claim rejections and unpleasant surprises during a medical emergency. You also know that every health insurance policy comes with its own set of inclusions, exclusions, waiting period, and claim conditions. Given this, there is no scope for confusion now.

If you are a first-time buyer or someone wanting to switch to another plan, Kissht brings together various health insurance plans from leading insurers. So, compare coverage, benefits, and premiums before making a decision.

FAQs

• What is covered under health insurance?

Health insurance covers medical costs such as in-patient hospitalisation, pre- and post-hospitalisation expenses, day care procedures, and more.

• What is not covered under health insurance?

Health insurance does not cover costs such as pre-existing diseases during the waiting period, cosmetic surgeries, voluntary abortion, and more.

• What factors affect health insurance policy coverage?

Health insurance policy coverage depends on the plan type, sum insured, insurer terms, waiting periods, exclusions, and selected add-ons.

• Who is not eligible for health insurance in India?

There is no fixed category of people ineligible for health insurance in India. However, insurers may decline applications based on factors or conditions outside the scope of health insurance coverage. 

• Can I use cashless treatment at any hospital?

No. Cashless treatment is available only at hospitals that are part of the insurer’s approved network. 

• Can I switch my health insurance policy to another insurer?

Yes. Eligible policyholders can switch their policy through health insurance portability, subject to the new insurer's terms. Kissht lets you compare health insurance plans from leading insurers before making the switch.

• How can I choose the right health insurance plan coverage?

The right health insurance plan coverage depends on your healthcare needs, family requirements, budget, preferred hospitals, and the benefits included in the policy.

• What are some health insurance benefits?

Health insurance benefits include protecting your savings from high medical expenses, managing the impact of rising healthcare costs, and offering tax deductions under the Income Tax Act.