We all know that a Health insurance policy doesn’t cover everything. There are certain treatments, medical conditions, and even items like equipment or supplies that insurance companies do not pay for. These are listed under the “exclusions” section of the policy.
But while most people are aware of what a health insurance plan does cover, very few pay attention to what it doesn’t. Insurance companies, agents, and intermediaries usually highlight the coverage benefits of health insurance policies, the exclusions are often ignored. Yet, the list of exclusions is usually long and becomes painfully relevant when it’s time to make a claim.
That’s when the reality hits, when you realize that something you assumed was covered actually isn’t. This often leaves people feeling disillusioned about insurance altogether. That’s why it’s just as important to understand what a policy doesn’t cover as it is to know what it does.
Before 1 October 2020, insurance companies in India were using their own terms and conditions for exclusions, that is – what was not covered, in health insurance policies. That was creating a lot of confusion for policyholders, as the exclusion terms were varying not just across insurance companies but within the different health insurance products of the same insurance company.
To remove this confusion and bring standardisation and uniformity across the industry, IRDAI brought Guidelines on Standardization of Exclusions in Health Insurance Contracts on 27th September 2019 through its circular IRDAI/HLT/REG/CIR/177/09/2019. This circular has played a key role in introducing the standardisation of exclusions in health insurance policies.
IRDAI has defined 18 exclusions in this circular and asked insurance companies to incorporate these 18 exclusions verbatim in all health insurance policies. Even the codes used by IRDAI to these 18 exclusions must be used exactly as they are by insurance companies in their health insurance policies.
In this article, I have discussed these exclusions in detail with examples so that you can grasp their essence and be aware of what is not covered in your health insurance policy. Whatever the health insurance policy you may have, these exclusions are part of your policy.
Standard Exclusions In Health Insurance Policies
Note: Green highlighted text shows the 18 standard exclusions, and blue text shows the standard wording for these exclusions as recommended by IRDAI. These wordings are part of all health insurance policies in India.
Pre-Existing Diseases (Excl01)
(a) Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of ## months of continuous coverage after the date of inception of the first policy with insurer.
We will try to understand these exclusions with examples. Suppose Ravi buys a ₹5 lakh Health Insurance Policy from Niva Bupa Insurance company on 1 Jan 2025 that policy has a waiting period of 36 months for pre-existing diseases.
At the time of policy purchase, Ravi was suffering from a kidney stone-related issue. Now, Niva Bupa policy will not pay the claim related to kidney stone treatment till the expiry of the waiting period that is, 36 months. Therefore, treatment cost related to kidney stone will be paid in the 4th policy starting from 1 Jan 2028 onwards.
(b) In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.
If Ravi increases his sum insured (like from ₹5 lakh to ₹8 lakh in 2026 on renewal), the new amount (₹3 lakh extra) will again have the 36-month waiting period for kidney stone-related illness (Pre-existing disease).
Ravi increased sum insured by ₹3 lakh in 2026; this new ₹3 lakh sum insured will cover kidney stone-related treatment expenses from 1 Jan 2029 onwards policy.
(c) If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.
Now, Ravi, having a health insurance policy from Niva Bupa, wants to transfer(port) this policy in 2027 (after 2 years with Niva Bupa) to a Star Health policy which also has a waiting period of 36 months for pre-existing diseases. If he has continuously renewed the policy with Niva without any break, then only 12 months of waiting will be left for pre-existing diseases (since 24 months are already completed with Niva Bupa).
(d) Coverage under the policy after the expiry of ## months for any pre-existing disease is subject to the same being declared at the time of application and accepted by Insurer.
Even after the waiting period (e.g., 36 months), the Niva Bupa/Star Health or any other insurance company will only cover the pre-existing disease (PED) if Ravi had told the insurance company about his kidney stone issue while buying the policy, and the insurance company has accepted it to cover this condition after waiting period.
However, in this example, I have taken 36 months as the waiting period. This is also the maximum period a policy can have as a waiting period for pre-existing diseases/illnesses/conditions as per IRDA guidelines.
Specified disease/procedure waiting period (Excl02)
(a) Expenses related to the treatment of the listed Conditions, surgeries/treatments shall be excluded until the expiry of #### months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an accident.
Suppose Ravi buys a ₹5 lakh health insurance policy from Niva Bupa on 1 Jan 2025, and the policy has a waiting period of 24 months for specified diseases like kidney stone, hernia, cataract, etc.
If Ravi is diagnosed with kidney stone in 2026, Niva Bupa will not pay for the treatment unless the 24-month waiting period is over. So, treatment cost for this condition will be covered only in the 3rd policy year starting from 1 Jan 2027. If Ravi takes treatment for kidney stone before 1 Jan 2027, his claim will be rejected under this clause.
(b) In case of enhancement of sum insured, the exclusion shall apply afresh to the additional amount.
If Ravi increases his sum insured from ₹5 lakh to ₹8 lakh in Jan 2026, the new ₹3 lakh sum insured will have a fresh 24-month waiting period for specified diseases like kidney stone. So, the ₹3 lakh increase will only cover kidney stone expenses from 1 Jan 2028 onwards.
(c) If any of the specified diseases/procedures also fall under the pre-existing disease waiting period, then the longer waiting period will apply.
For example, if Ravi’s kidney stone was already existing before the policy started (PED) and the PED waiting period is 36 months but the specified disease waiting period is 24 months, then 36 months will be applicable, because it is longer.
(d) The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.
So even if Ravi develops kidney stone after buying the policy or had declared it and Niva Bupa accepted it without special exclusion, the waiting period will still apply – claim will be allowed only after the waiting period ends.
(e) If the Insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.
Suppose Ravi had a health policy from Star Health since Jan 2023, and ports to Niva Bupa in Jan 2025 with no break. If Niva Bupa policy has a 24-month waiting period for kidney stone, but Ravi has already completed 24 months with Star Health, then no waiting will apply now, kidney stone treatment will be covered immediately from day one in Niva Bupa.
Every health insurance policy has such list of diseases or procedures mentioned in policy document and that list is not standard across insurance companies.
30-day waiting period (Excl03
(a) Expenses related to the treatment of any illness within 30 days from the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.
Ravi has a ₹5 lakh health insurance policy from Niva Bupa starting form 1 Jan 2025. If Ravi gets fever, infection, or any illness and needs hospitalization on 15 Jan 2025, Niva Bupa will not pay for this claim, because it happened within the first 30 days of policy issuance.
However, if Ravi meets with an accident and is hospitalized on 15 Jan 2025, the claim will be paid, since accidental treatments are covered from day 1.
(b) This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.
So, from Ravi’s second policy year onwards (from 1 Jan 2026), no such 30-day waiting period will apply, he’ll be covered from day 1 of each renewal year.
(c) The within referred waiting period is made applicable to the enhanced sum insured in the event of granting higher sum insured subsequently
Suppose Ravi increases his sum insured from ₹5 lakh to ₹8 lakh in Jan 2027, then this extra ₹3 lakh will have a fresh 30-day waiting period for illnesses.
So, if he is hospitalized for fever or any non-accidental illness within 30 days of enhancement, the ₹3 lakh extra will not be available, but the original ₹5 lakh will still be eligible.
Investigation & Evaluation (Excl04)
(a) Expenses related to any admission primarily for diagnostics and evaluation purposes only are excluded.
This means if a person is admitted in a hospital and only diagnostics tests like blood tests, CT Scan, MRI etc are only done and no treatment is taken during hospitalsiation then insurance company will not pay the claim.
Many people believe that if you’re hospitalized for more than 24 hours, your health insurance claim will automatically be approved. But that’s not true. The hospital stay must be medically necessary for the illness, and there should be active line of treatment during the hospitalization. Simply staying in the hospital for observation or getting routine medical tests done does not qualify for a claim.
(b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and treatment are excluded.
Ravi is admitted for kidney stone treatment, but the hospital also conducts a heart test or eye test. Since these tests are not connected to the kidney stone problem, the cost of these tests will not be covered by insurance.
Rest Cure, rehabilitation and respite care (Excl05)
Expenses related to any admission primarily for enforced bed rest and not for receiving treatment. This also includes:
I. Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.
Ravi suffers a minor injury, and doctor says, “You need complete bed rest for 10 days.” Ravi gets admitted to a hospital or nursing home just for bed rest, no surgery, no medicines, no active treatment. In this case, insurance company will not pay the claim because it’s considered rest cure, not treatment.
II. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.
If Ravi is terminally ill (like with advanced-stage cancer), and is admitted just for comfort and emotional support, not for curing the disease, like to reduce pain, provide spiritual or emotional care, then insurance will not pay for such care.
This is called respite care or palliative care, and it’s meant to provide comfort, not treatment, so it’s excluded from health insurance.
Obesity/ Weight Control (Excl06)
Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions:
1) Surgery to be conducted is upon the advice of the Doctor
2) The surgery/Procedure conducted should be supported by clinical protocols
3) The member has to be 18 years of age or older and
4) Body Mass Index (BMI);
a) greater than or equal to 40 or
b) greater than or equal to 35 in conjunction with any of the following severe co-morbidities following failure of less invasive methods of weight loss:
i. Obesity-related cardiomyopathy
ii. Coronary heart disease
iii. Severe Sleep Apnea
iv. Uncontrolled Type2 Diabetes
If you closely read this exclusion, it is basically a coverage for obesity-related treatments, provided certain conditions are met. Actually, IRDAI has directed insurance companies to include weight control/obesity-related surgeries, known as bariatric surgeries, in health insurance policies. Later, through these wordings, IRDAI has formally provided coverage for obesity treatment.
However, all health insurance policies carry this standard exclusion term, which means that by default, they now cover obesity-related treatments. But insurance companies have also added their own limitations on the coverage of these treatments, as they are very expensive and prone to misuse.
For example, Star Health’s comprehensive insurance policy covers bariatric surgery only up to ₹2.5 lakh, and that too after a waiting period of 36 months.
Therefore, mere inclusion of this treatment by IRDAI is not enough; one must also check if there are other terms in the policy that limit this coverage.
Change-of-Gender treatments (Excl07)
Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.
Suppose Ravi, who is biologically male, decides to undergo gender transition surgery to become female. This involves various medical procedures like – Hormone therapy, Genital reconstruction surgery etc. In this case, health insurance policy will not pay for any of these procedures, even if it involves surgery, hospital stay, or expensive treatment.
Cosmetic or plastic Surgery (Excl08)
Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner
If surgery is done just for cosmetic reasons, it’s not covered. But if it’s done to repair damage after an accident, burn, or cancer, or to avoid a health risk, and the doctor recommends it, then insurance companies cover the expenses.
Lets understand this by examples:
Example 1 – Not Covered:
Ravi feels his nose is too big and wants to get nose reshaping surgery (rhinoplasty) done to look better. He goes to a cosmetic surgeon and gets the procedure done. As this is for appearance only, not because of any illness or injury. So, insurance company will not pay for this.
Example 2 – Covered:
Ravi meets with a road accident, and his face gets injured badly. The doctor advises reconstructive plastic surgery to fix the facial bones and restore normal appearance. Since this surgery is due to an accident, and is medically necessary, Insurance company will pay for it.
Example 3 – Covered:
Ravi is diagnosed with oral cancer, and after surgery, part of his jaw is removed. Later, doctors perform reconstructive surgery to rebuild the jaw. Since this is due to cancer treatment, it is payable under health insurance policy.
Example 4 – Maybe Covered (Needs Doctor’s Certificate):
Suppose Ravi has excess skin on his eyelids that blocks his vision, and doctor says surgery is needed to avoid permanent eye damage. If the doctor certifies this surgery as medically necessary to prevent a serious health issue, insurance policy may cover it.
Hazardous or Adventure sports (Excl09)
Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.
This exclusion is self-explanatory: if a professional, someone who is routinely involved in adventurous sports due to the nature of their work, gets injured while participating in such activities, the cost of treatment for that injury is not covered under the health insurance policy.
However, an important point to note is that if you are a non-professional and engage in adventurous sports purely for entertainment or fun, and happen to get injured, then the expenses related to that injury are covered.
The logic is simple: a professional is more exposed to risk and has a higher chance of getting injured because of their job, compared to a non-professional who takes part occasionally just for fun. That said, some insurance policies do put a limit or cap on the total expense payable for such hospitalisation events. For instance, the National Insurance Parivar Mediclaim policy has such a cap in place.
Breach of law (Excl10)
Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.
Lets understand this by example – Ravi was riding a bike at high speed, without a helmet, and was drunk. Police later found he was under the influence of alcohol, which is against the law.
He meets with a serious accident and is admitted to the hospital. Now, even though it’s an accident, the insurance company can refuse the claim because Ravi was breaking the law (drunk driving).
Excluded Providers (Excl11)
Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations following an accident, expenses up to the stage of stabilization are payable but not the complete claim.
There are a few hospitals that are marked as excluded providers, and the insurance company maintains a list of such hospitals on its website. Sometimes, the names of these hospitals are also printed on the insurance policy itself. The insurance company does not pay claims for hospitalisation at these excluded hospitals.
However, in life-threatening situations, the insurance company may cover the claim to a certain extent until the patient is stabilised. To avoid any hassles, it’s best to avoid these hospitals whenever possible.
Treatment for, Alcoholism, drug or substance abuse or any addictive condition and consequences thereof. (Excl 12)
For example Ravi has been drinking heavily for many years. One day, he starts having severe liver problems and gets admitted to hospital. Doctors say it’s due to alcohol-induced liver damage. Since the illness is caused by alcoholism, Insurance company will deny the claim in this case.
Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Excl13)
If you go to a spa, naturopathy center, or resort for treatment or rest, or admit just because home help is not available, it’s not covered by health insurance.
For example – Suppose Ravi’s father is old and slightly weak, but not seriously ill. Ravi is going on a business trip and there’s no one at home to take care of his father. So Ravi admits him to a private nursing home for a few days. His father is not admitted due to any real medical emergency and admission was done only for domestic convenience. So in this case, Insurance company will deny the claim.
Dietary supplements and substances that can be purchased without prescription, including but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure. (Excl14)
This exclusion means, if you buy vitamins or health supplements on your own, it’s not covered.
If doctor gives them as part of your treatment during hospitalization, then it’s covered.
For example, Ravi takes Vitamin D and calcium tablets just to stay healthy. He does this on his own, without any prescription. Since these supplements are not related to any hospital treatment or doctor’s advice, the insurance company will not pay for them.
However, if Ravi gets admitted to the hospital due to a bone fracture, and the doctor prescribes calcium and Vitamin D as part of his treatment during his stay, then these supplements will be covered by insurance, because they are medically necessary and directly part of the hospitalization treatment.
Refractive Error (Excl15)
Expenses related to the treatment for correction of eye sight due to refractive error less than 7. 5 diopters.
This exclusion also covers Lasik surgery for eye indirectly. If your specs number is more than 7.5D then you can go for Lasik treatment for refractive error correction and that will be covered by health insurance. For more details read this –Lasik Surgery Coverage In Health Insurance In India
Unproven Treatments (Excl16)
Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.
Unproven treatment, services and supplies” means – medical treatments, procedures, tests, or medicines that do not have strong scientific proof that they actually work and not approved by the medical authorities (like ICMR, WHO, or other recognized medical bodies).
For example, Ravi hears about a new therapy that claims to cure joint pain using magnetic waves. The clinic offering it says it’s “natural” and “alternative,” but it is not approved by medical science and lacks proper research or documentation. Ravi tries this treatment and spends a good amount of money.
Since this treatment is not recognized as effective by the medical community and is not backed by scientific evidence, the insurance company will not reimburse him for the expenses.
Birth control, Sterility and Infertility (Excl17)
Expenses related to Birth Control, sterility and infertility. This includes: (i) Any type of contraception, sterilization
(ii) Assisted Reproduction services including artificial insemination and advanced reproductive technologies such as /VF, ZIFT, GIFT, /CS/
(iii) Gestational Surrogacy
(iv) Reversal of sterilization
For example Health insurance will not pay for any treatment related to avoiding pregnancy or trying to get pregnant. It also doesn’t cover if someone is unable to have children (infertility) and takes treatment for that.
If Ravi and his wife decide not to have more children and Ravi goes for sterilization (like vasectomy) or his wife goes for tubal ligation, the cost of this procedure will not be covered.
If a couple is unable to have a child and they go for treatments like IVF (test tube baby), artificial insemination, or any other advanced fertility treatments, all these are excluded from insurance. So, they have to bear the cost on their own.
If someone goes for surrogacy, where another woman carries the baby for them, even this cost is not covered.
Also, if someone had sterilization done earlier and now wants to reverse it, even that surgery or procedure won’t be paid by the insurer.
But now a days a number of health insurance policies are covering expenses for ART (Assisted Reproductive Technology) and other advanced infertility related treatments. Where policy is covering such expenses, then this term is modified accordingly.
Maternity (Excl18)
(a) Medical treatment expenses traceable to childbirth (including complicated deliveries and caesarean sections incurred during hospitalization) except ectopic pregnancy.
This means expenses for normal delivery, complicated deliveries, or a caesarean section (C-section) are not covered. However, treatment expenses due to ectopic pregnancy (where the pregnancy happens outside the uterus) is covered by health insurance policies without any limit.
(b) Expenses towards miscarriage (unless due to an accident) and lawful medical termination of pregnancy during the policy period.
If someone experiences a miscarriage, the treatment costs are not covered unless the miscarriage is caused by an accident.
Similarly, lawful medical termination of pregnancy (abortion) is not covered during the policy period.
But insurance policies’ now a days are covering delivery expenses. Where policy is covering maternity then this term is modified accordingly.
Can insurance companies include exclusions beyond the 18 specified by IRDAI?
Short answer is Yes. The primary purpose of IRDA guidelines was to bring uniformity and standardisation by defining 18 standard exclusions. Ideally, insurance policies should not have any exclusions beyond these.
However, in reality, policies do have a few additional exclusions apart from the IRDA-defined ones. These extra exclusions vary slightly across insurance companies, but overall, they are more or less similar.
Below are some specific exclusions beyond the IRDA-defined list:
- Circumcision – Removing the foreskin of the penis. It’s not covered unless it’s needed to treat a disease or due to an injury.
- Expenses will not be covered if you are admitted just for general tiredness, weakness, or recovery after an illness (called convalescence), or for problems due to poor nutrition or being in a run-down condition.
- Any hospitalsiation due to attempted suicide or intentional self harm/injury
- War and nuclear material related injuries.
- Expenses incurred on Enhanced External Counter Pulsation(EECP) Therapy and related therapies, Chelation therapy, Hyperbaric Oxygen Therapy, Rotational Field Quantum Magnetic Resonance Therapy, VAX-D, Low level laser therapy, Photodynamic therapy
- Stem cell and similar procedures– These Treatments are not covered
- Using your own stem cells (stromal vascular fraction)
- Chondrocyte implantation (for cartilage repair)
- Platelet Rich Plasma therapy
- Injections into joints (intra-articular) – Like Hyaluronic injection in knees.
- Biological drugs (like advanced injections or treatments made from living organisms) are only covered if they are given during hospital admission and are medically necessary.
- Vaccinations are not covered, except: After an animal bite (like rabies shots) Or when needed as part of treatment (not general preventive vaccines).
- Hospital registration charges, admission charges, record charges, telephone charges and such other charges
- Aids and devices expenses are not covered for:
- Cochlear implants (used for hearing) and procedure charges
- Spectacles, contact lenses charges
- Hearing aids, crutches, walkers, wheelchairs
- Breathing machines (like CPAP, BIPAP), dialysis machines, or pumps.
Are insurance companies allowed to modify the wording of the exclusions defined by IRDAI?
Insurance companies in India have included these exclusion in their policies exactly as defined by IRDAI, except for the ones against which they are offering coverage.
For example, if a health insurance policy covers maternity, then the maternity-related exclusion is modified as per the extent of coverage provided. Insurance companies can choose to give coverage against any or all of these exclusions, but if they are not covering any exclusion or part of it, then they can’t change the standard definition of that exclusion.
This is all about exclusions in Health Insurance policies. I hope this has clarified all your doubts, if you still have any query, post your query in comment section of post.
Sources and Reference:
1. Guidelines on Standardization of Exclusions in Health Insurance Contracts IRDAI (IRDAI/HL T/REG/CIR/ 117 /09/2019)
2. Star comprehensive Insurance policy
3. National Insurance Parivar Mediclaim policy
4. IRDA circular on pre-existing disease
5. IRDAI master circular on Health Insurance Business 29.05.24
