Page 160 - Ebook health insurance IC27

The Insurance Times

(i) Pre- existing illness - This exclusion of pre-existing illnesses have been the
subject of many legal interpretations, a lot of consumer grievances and
considerable media attention. In recent years many insurers have started
covering pre-existing diseases after the completion of standard number of
years (usually 4 year).

(j) Exclusions - Insurers normally do not entertain all claims by customers and
impose some restrictions. The rationale behind this is to avoid staged or fraudulent
claims, misuse of insurance for profits, and to keep claim costs lower, and thus
indirectly keep the premium costs lower. However, customers usually do not fully
understand the conditions and many such trust issues arise. Some of the common
exclusions are :
(1) Pre-existing illness
(2) Diseases contracted during initial waiting period
(3) Expenses on treatment of Hernis, Hydrocele, Fistula, Cataract etc , which
require time to reach operational stage
(4) Injury/disease due to war, and war like operations
(5) Cosmetic/ plastic surgery without accidental/surgical requirement
(6) Dental treatment
(7) Drug abuse/Alcohol usage
(8) Naturopathy treatment and
(9) Non medical expenses for personal comfort like TV, telephone, toiletry
items etc.

(k) Cancellation Clause - Usually this clause cam be evoked by the insurer for
reasons of fraud, moral hazard, misrepresentations or non-cooperation of the
insured. Similarly, the customer may also cancel the policy based on policy
conditions andtheinsurancecompany issupposed to refund thepremium. However,

164 Guide for Health Insurance