The Real Reason Health Insurance Claims Get Rejected | Don't MISS this if you have insurance | Ditto

Okay. Do you know what you see on your screen? Policy documents from five different insurers.

And today I'm going through a section in this policy wording that 90% of you miss reading which can lead to claim rejections or denials and eventually you ending up paying out of pocket. So if you never want to pay out of pocket and want your insurance to work for you perfectly like it should, watch till the very end as I will be listing out how to avoid such a situation. See, most people do buy health insurance believing that it covers everything related to health.

But in reality, every health insurance policy comes with something called exclusions. In today's video, we're breaking down exclusions in health insurance. What they are, why they exist, which ones are permanent, which ones go away with time, and most importantly, how you can avoid surprises during the claim time.

Hello folks, I'm Shashank and you're watching DTO insurance. We've helped over 10 lakh Indians choose the right plan without pressure or spamming. That's why we remain one of the most trusted advisers in the market.

If you want to experience our service for free, try it out by booking a free call with the link in the description. Now, before we go deeper, here's the first thing that you need to understand. In health insurance, exclusions are simply treatments, conditions, or expenses that your insurer will not pay for.

And exclusions are not there to cheat you. They exist for three very practical reasons. To make sure people don't buy insurance only after they fall sick, to keep premiums affordable for everyone.

and to avoid covering costs that are predictable, non-medical or impossible to price fairly. Okay, now that we know what exclusions are, let's understand the two types of exclusions. Permanent exclusions and temporary exclusions.

Permanent exclusions are things that are never covered no matter how long you hold the policy for. For example, cosmetic and aesthetic treatments. Procedures like Botox, liposuction, hair transplants, or cosmetic dental works are not covered unless they are specifically medically required due to an accident.

If it's done to improve appearance, insurance won't pay. Then there are non-medical and admin expenses. Things like registration charges, admission fees, service charges, and sometimes even diagnostic tests done without a doctor's prescription.

These are not considered medical treatment, which is why insurers are allowed to exclude them. Self-inflicted injuries or conditions arising from alcohol or substance abuse or injuries during illegal activities are also permanently excluded. This includes suicide attempts or complications linked directly to substance misuses because insurers legally cannot encourage illegal activities.

Fertility and pregnancy related expenses are another big permanent exclusion. IVF, IUI, surrogacy, and elective abortions are not covered because it's a high-end and predictable expense. Look, these won't get covered unless your policy includes a maternity benefit or rider.

Congenital conditions present since birth are viewed as pre-existing and lifelong, making it difficult for insurers to offer coverage. Likewise, experimental or unapproved treatments like certain gene or stem cell therapies and injuries due to a war or nuclear events are also permanently excluded across almost health insurance policies. And finally, OPD and preventive care.

Look, doctor consultations, routine tests, medicines, and vaccinations are usually not covered as they're meant for regular upkeep and not hospitalization. So, it won't get covered unless your plan specifically includes OPD or wellness benefits. These exclusions, as I mentioned, don't disappear over time.

Waiting longer doesn't help here as well. Now, heading to the next bit that is temporary exclusions. Before we dive in, if you're someone who is okay with paying out of pocket despite holding a strong insurance, by all means, you can skip this next part.

But if you want your insurance to actually work for you, then get your policy checked with our ID certified advisor for free. There's no pressure. Links in the description.

Now these are treatments or conditions that are not covered initially but are covered after a waiting period. The most common one is initial waiting period. The first 30 days after you buy a health insurance policy, any illness is not covered.

Only accidents are covered from the day one. This is standard across insurance. Then comes pre-existing diseases.

Conditions like diabetes, blood pressure, asthma, thyroid issues or heart diseases are usually covered only after a waiting period of 1 to 3 years depending on the policy. There is also something called as specific illness waiting period. Treatments like hernia, catact, knee replacement, gallstones, piles or kidney stones often have a 1 to twoyear waiting period because these are slow developing diseases.

And here's an important thing to watch out for. Some insurers include serious diseases like cancer under this list. Now that's a red flag.

At DTO, we generally consider such plans only as last resort when no other option is available. Maternity expenses are another temporary exclusion. Even when covered, maternity benefits usually start only after a waiting period ranging from anywhere between 9 months to 4 years.

Folks, if you're already holding a health insurance policy and you're not sure what exclusions or waiting periods apply to you, this is a good time to pause the video and actually check your policy wording or we'll make it easier for you. You can book a free call with Advisor and we'll read it with you and explain exactly where the gaps are. Now that we know what exclusions are, let's see how you can actually deal with them.

Now, this is where riders and add-ons come into the picture. As you know, riders are optional covers that you buy along with your base policy to override or reduce exclusions. A maternity rider can cover delivery costs, newborn care, and vaccinations after the waiting period.

A pre-existing disease waiver can reduce the waiting period for conditions like diabetes or BP, sometimes even to zero. Specific illness waiting period reduction riders can shorten or completely remove the 2-year waiting period on surgeries. Consumables or non-medical expense riders cover things like gloves, syringes, PP kits, and surgical items that hospitals routinely bill, but insurers often exclude.

Now, these alone can make up to 5 to 15% of your hospital bill. So, getting this rider is actually a wise decision. There are also OPD riders, hospital cash benefits, durable medical equipment covers, and even global treatment riders for serious illnesses.

But let me tell you something important. Not every rider is necessary and not every plan needs riders. Some modern health insurance plans already include coverage for many commonly excluded items as an inbuilt feature.

That's why blindly comparing premiums is a bad idea, folks. The real comparison should always start with exclusions, which brings me to the final bit. Where do you actually find the exclusions?

You'll find them in the sections called exclusions, waiting periods, and standard general terms and clauses inside the policy wording. If you guys would like to check out some sample exclusions list, I have linked the policy wordings of HDFCO Care Supreme ICICU Adita Burla and Nabupa Aspire Titanium Plus in the description. Go take a look.

Folks, let me remind you that you can always book a free call with DTO's advisor who will help you understand exclusions, suggest better alternatives if needed, and make sure your insurance actually works when you need it. Links in the description. All right, folks.

I will see you in the next one. Until then, happy insurance hunting.