A health insurance policy provides financial protection against medical expenses, however, most insurance policies have some specific exclusions. The average policy holder only realizes these exclusions when they file a claim.
Every health insurance plan has its own set of exclusions. Some of these exclusions are common across health insurance plans while some others are specific to the policy.
This guide will break down the common exclusions in most health insurance policies in Pakistan and how you can mitigate their impact.
Most health insurance policies do not cover pre-existing conditions for a certain period, usually ranging from one to four years. A pre-existing condition is any illness or medical condition diagnosed before you buy a policy. This could be diabetes, hypertension, or heart disease. Some insurers may provide coverage after a waiting period, while others may exclude them permanently.
Waiting period in health insurance refers to the period before which certain conditions are not covered under your health insurance policy. Your policy starts covering these conditions only after you serve the waiting period fully.
How to Mitigate: Choose a policy with a shorter waiting period or opt for plans specifically designed for individuals with pre-existing conditions. Some insurers allow policyholders to reduce waiting periods by paying higher premiums.
Health insurance policies usually do not cover treatment or surgical costs rising due to obesity or plastic surgery. These are usually categorized under cosmetic procedures. However, if such procedures are rendered necessary due to an illness, injury or accident, your health insurance policy should cover them.
How to Mitigate: If cosmetic procedures are important, consider saving separately or checking if employer-sponsored plans offer partial coverage. In some cases, reconstructive surgery after an accident is covered, so verify that with your provider.
Standard health insurance plans do not cover routine dental checkups, orthodontic treatments, eyeglasses, and contact lenses. Some policies do offer coverage for dental or vision related expenses only in case of accidents.
How to Mitigate: Look for add-on coverage riders for dental and vision care or explore standalone insurance plans that provide these benefits. Many corporate health insurance plans offer separate vision and dental benefits.
Many individual health insurance plans exclude maternity expenses, including prenatal and postnatal care, childbirth, and newborn medical care. These can be added on through riders to the existing policy with additional charges.
How to Mitigate: you can pick a maternity-specific insurance plan or check if your employer provides maternity benefits as part of group health coverage. Some insurance providers allow policyholders to include maternity riders at an additional cost.
Alternative medicine like homeopathy, acupuncture, and naturopathy, are generally excluded from health insurance coverage. Similarly, experimental treatments or therapies that have not received regulatory approval are not covered.
How to Mitigate: If you prefer alternative medicine, look for policies that offer limited coverage or set aside funds for these treatments. Some comprehensive policies have the flexibility to include coverage for alternative therapies, so it’s worth comparing options.
Health insurance policies do not cover any treatment which is needed due to alcoholism or substance abuse. If you smoke, or consume alcohol or drugs, and end up needing treatment because of these habits, your health insurance policy will not cover your treatment.
How to Mitigate: If substance abuse treatment is needed, explore specialized rehabilitation programs that offer financial assistance. Some mental health insurance plans now provide partial coverage for addiction treatment.
No health insurer will be keen to cover treatment when it is due to an injury caused by participation in any hazardous or adventure sports. So you can either stop participating in such sports or be cautious while participating in them.
How to Mitigate: Some insurers offer additional riders for extreme sports coverage, so inquire about these options if you participate in high-risk activities. If your profession involves hazardous work, explore occupational health insurance plans.
Procedures such as in-vitro fertilization (IVF), surrogacy, and other fertility treatments are generally not covered by standard health insurance policies. However, some policies allow for fertility treatment riders for additional charges
How to Mitigate: If you require fertility treatments, check for specialized plans or employer-sponsored benefits that offer some level of coverage. Some premium insurance providers offer partial coverage for fertility treatments.
While mental health awareness is improving, many traditional health insurance policies still exclude mental health treatments, including therapy, counseling, and psychiatric care.
How to Mitigate: Look for insurance providers that include mental health coverage or seek standalone mental health plans. Some progressive insurers are now offering mental health benefits as part of comprehensive coverage.
Over-the-counter medications, vitamins, supplements, and experimental drugs are typically excluded from coverage unless prescribed as part of an inpatient hospital treatment.
How to Mitigate: Budget separately for non-prescription medications or seek employer-sponsored healthcare plans that offer reimbursement options. Some insurance companies offer drug coverage riders that include a wider range of medications.
Many health insurance policies do not cover medical expenses incurred outside of Pakistan, except for emergency treatments.
How to Mitigate: If you travel frequently, consider an international health insurance policy or travel medical insurance that covers overseas medical expenses.
Most health insurance policies do not cover long-term nursing care, assisted living, or home care services for chronic illnesses or disabilities.
How to Mitigate: If long-term care is a concern, look into long-term care insurance plans or family support options.
Understanding exclusions is the first step toward selecting the right health insurance plan. Here are a few tips:
Having a health insurance policy is a valuable financial safety net, but no policy covers everything. Understanding exclusions in the policy you pick helps you plan better and avoid unexpected medical costs. Before buying a policy, assess its coverage limitations carefully, compare different options, and consider add-ons that match your healthcare needs.
By staying informed, you can make the best decision for yourself and your family.
Sadia Zaheer holds a Masters in Business Administration from IBA, Karachi. After working in several financial institutions in Client Management, Corporate Lending, Islamic Banking and Product Management she jumped careers to pursue a career in writing.
She is a Finance, Business and HR Development writer with four years of experience. She reads a lot and takes care of her multiple cats to remain calm.
This post was last modified on March 10, 2025 11:16 am
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