In a world where health uncertainties can arise unexpectedly, having a comprehensive health insurance plan is crucial for individuals and families. In India, with its diverse healthcare landscape and increasing medical costs, understanding the diseases covered under health insurance plans becomes paramount. This article looks into the various diseases and medical conditions that are typically covered by health insurance policies in India. By shedding light on these essential coverage areas, we aim to empower individuals and businesses to make informed decisions when choosing health insurance or group health insurance plans, ensuring they receive the necessary financial protection and access to quality healthcare services.

Diseases Covered Under a Typical Health Insurance Policy in India

A typical health insurance plan in India covers a wide range of diseases and medical conditions. While the specific coverage can vary depending on the insurance provider and policy, here are some common diseases and conditions that are often covered under health insurance plans in India-

  • Infections and Illnesses: Health insurance plans generally cover common infectious diseases such as pneumonia, typhoid, malaria, dengue and hepatitis. Coverage may also extend to other illnesses like bronchitis, sinusitis, urinary tract infections and gastrointestinal infections.
  • Chronic Diseases: Health insurance often covers chronic diseases such as diabetes, hypertension (high blood pressure), asthma, arthritis, thyroid disorders, and chronic kidney disease. These conditions require ongoing management and treatment, and health insurance helps individuals access the necessary medical care.
  • Cataract: Cataract surgery is one of the most popular surgical procedures in India, with more than 14 million surgeries performed each year. Depending on the technique and complications, the surgery can cost anywhere from Rs. 15,000 and Rs. 1 lakh. After an initial waiting period, most health insurance policies cover cataract surgery.
  • Cardiac Conditions: The heart is one of our body's most crucial and complicated organs. Cardiovascular ailments impair normal heart function and impact the entire body, which can be fatal. Health insurance plans typically provide coverage for cardiac conditions, including heart attacks, coronary artery disease, angina, and heart failure. Coverage may include diagnostic tests, cardiac procedures, surgeries, and post-operative care.
  • Cancer: Cancer is a dangerous disease that affects a large number of people. Although medical advances have increased the odds of recovery from many types of cancer, the expense of these therapies continues to rise. Most health insurance plans cover cancer treatment, including chemotherapy, radiation therapy, surgeries, and supportive care. However, the coverage may be subject to certain limitations or waiting periods, so it is important to review the policy details.
  • COVID-19: COVID-19 is a highly contagious virus infection produced by the SARS-CoV-2 virus. The symptoms might range from mild flu-like symptoms to life-threatening diseases such as pneumonia and multiple organ failure. Many health insurance policies cover hospitalization and other medical expenditures if you become infected with the coronavirus.
  • HIV/AIDS: HIV/AIDS patients have a weakened immune system and are more vulnerable to a variety of problems. It is expensive to treat this disease for any middle-class Indian. Fortunately, many insurance policies in India cover the cost of HIV/AIDS therapy. Hospitalization fees, treatment costs, daycare therapy, and a variety of other expenses are all covered by different comprehensive health insurance policies.

Get Free Quote in Minutes

  • Accidents and Injuries: Health insurance plans generally cover medical expenses related to accidental injuries, fractures, burns, and trauma. Emergency room visits, ambulance services, surgeries, and follow-up treatments are typically included.
  • Maternity and Childbirth: Many health insurance plans offer coverage for maternity expenses, including prenatal care, delivery, and postnatal care for both mother and child. Some policies also cover newborn vaccinations and childcare.
  • Organ Transplants: Health insurance plans often provide coverage for organ transplantation surgeries, including kidney, liver, heart, and lung transplants. This coverage may include pre-transplant evaluations, surgery, post-transplant care, and immunosuppressant medications.
  • Mental Health: With increasing awareness about mental health, several health insurance plans now include coverage for mental illnesses such as depression, anxiety disorders, bipolar disorder, and schizophrenia. This coverage may extend to counseling sessions, therapy, and medication costs.
What Diseases are Not Covered by Health Insurance?
What Diseases are Not Covered by Health Insurance?

What Diseases Are Not Covered by Health Insurance?

With so many health insurance providers in India, you can choose any policy that meets your specific requirements. Certain circumstances and diseases, however, are not covered by health insurance policies. Some of these are as follows:

  • Cosmetic and Plastic Surgeries

Health insurance policies typically do not cover cosmetic and plastic surgeries unless they are necessitated by accidents or injuries. Procedures such as rhinoplasty, liposuction, and facelifts, which are performed for aesthetic purposes, are generally excluded from coverage. Insurance companies focus primarily on providing coverage for medically necessary treatments and surgeries.

  • Infertility therapies and treatments

Infertility treatments, including in-vitro fertilization (IVF), are generally not covered by health insurance policies in India. These treatments are considered elective procedures and fall outside the scope of coverage. However, some insurers may offer specific riders or add-ons that provide limited coverage for infertility treatments, but these options are still relatively rare.

  • Congenital Diseases and Birth Defects

Health insurance policies generally exclude coverage for congenital diseases and birth defects. These conditions refer to health issues that are present at birth or develop during the early stages of life. Since congenital diseases are often identified before or shortly after birth, they fall under the pre-existing disease category and are therefore excluded from coverage. It is advisable to explore separate insurance plans that cater specifically to congenital diseases if you have a family history or are at risk.

  • Pre-Existing Diseases

One of the key exclusions in health insurance policies is coverage for pre-existing diseases. A pre-existing disease refers to any ailment or condition that an individual had before purchasing the health insurance policy. Insurers often have a waiting period before they start providing coverage for pre-existing diseases, which can range from 2 to 4 years. This exclusion helps insurance companies mitigate the risk of insuring individuals who are already suffering from chronic illnesses. However, some insurers may provide coverage in such conditions as an add-on or on payment of an additional premium.

  • Alternative Therapies and Experimental Treatments

Most health insurance policies do not cover alternative therapies such as Ayurveda, Homeopathy, Naturopathy, and Unani treatments, as they are not considered mainstream medical practices. Experimental or unproven treatments, which lack scientific evidence or regulatory approvals, are also generally not covered.

  • Health problems induced by the use of Alcohol, drugs and other such substances

It is undeniable that drug users, smokers, and heavy drinkers are more vulnerable to lifestyle diseases than others. Some severe ailments, such as stroke, oral cancer, liver damage, bronchitis, and others, are caused by the use of excessive drugs, smoking, or alcohol intake. Under these conditions, health insurance coverage totally excludes claims.

  • Injuries caused by self

Intentional acts of self-harm fall outside the scope of such coverage. The reasoning behind this exclusion is to discourage individuals from intentionally harming themselves to seek financial benefits from their insurance policy. Including coverage for self-inflicted injuries could lead to moral hazard, where individuals may engage in risky behavior knowing they are protected financially.

The footnote:

Group health insurance plans in India offer a wide range of coverage for diseases, providing valuable protection to employees and their families. By understanding the diseases covered under group health insurance plans, employers can make informed decisions when selecting a comprehensive health insurance package for their workforce. These plans not only offer financial security but also ensure timely access to quality healthcare services. From common ailments to critical illnesses, group health insurance plans play a crucial role in safeguarding the well-being of employees and their dependents. With rising healthcare costs and increasing medical uncertainties, having the right group health insurance coverage becomes a crucial component of employee benefits in any organization.

It's important to note that each health insurance policy may have specific limitations, waiting periods, exclusions, and sub-limits for certain diseases or treatments. It is advisable to thoroughly review the policy terms and conditions to understand the extent of coverage for each disease or condition. Consulting with insurance professionals, facilitators or brokers can also help in selecting a health insurance plan that best suits individual healthcare needs. For more information on any topics related to business and insurance, you may contact BimaKavach. Here, you can also get the best recommendation for any insurance product in just 5 minutes.