The exclusions section is the most important and most ignored part of any insurance policy. Most claim rejections happen because the treatment, cause of death, or event falls under an exclusion the policyholder never read.
Types of exclusions
1. Absolute (permanent) exclusions
These are never covered, regardless of circumstances — e.g., war, nuclear disaster, self-inflicted harm, participation in criminal acts.
2. Waiting period exclusions
These are temporarily excluded: e.g., pre-existing diseases (typically 2–4 year waiting period), maternity (typically 9–24 months), specific diseases like hernia or cataract (typically 1–2 years).
3. Sub-limits and caps
Some expenses are covered but only up to a certain limit — e.g., room rent capped at 1% of sum assured, or cataract surgery capped at ₹40,000 per eye. These are not full exclusions but can leave you with large out-of-pocket costs.
Key phrases to look for
"Not covered", "excluded", "not payable", "sub-limit", "waiting period", "co-payment" — search for these words in your policy PDF. Every instance is a potential blind spot.
How to challenge an unfair exclusion
If you believe a claim has been rejected using an exclusion that was not disclosed to you at the time of purchase, or that the exclusion does not apply to your situation, raise a formal complaint. IRDAI has ruled against insurers who use exclusions unfairly or ambiguously.
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