Exclusions of IFFCO Tokio Individual Health Protector Policy
Following are the exclusions in case of which our company will not be able to compensate your claims:
- Frenuloplasty, Circumcision, Preputial Dilatation, Preputioplastyand Removal of SMEGMA.
- Expenses incurred on diagnostics that do not tally with the treatment for the ailment for which you or your family member has been admitted to the nursing home or hospital. Expenses on account of admission to the hospital mainly for diagnostic purpose without any positive existence of ailment/sickness /injury/disease and there is no further indication of any treatment being administered. Disease or injury directly or indirectly caused due to nuclear materials or weapons.
- Behavioural, Mental and Psychiatric ailments.
- Vaccination or Inoculation (other than post-bite treatment and for medical treatment for therapeutic reasons).
- Cosmetic or plastic surgery (other than necessary as a result of an illness or an accident).
- Unless necessitated due to accidental injuries warranting hospitalization, dental treatment or surgery are not payable. (Dental implants are not payable).
- Cost of Nutritional Supplements, hearing aids, infusion pump, spectacles and contact lens, Continuous Ambulatory Peritoneal Dialysis [CAPD], walkers and crutches, Cochlear implants, wheelchairs, CPAP, BIPAP and other such similar aids and procedures and associated expenses for hospitalization.
- Congenital External Defects /Anomalies and Conditions.
- Biologicals, Oral Chemotherapy and Immunotherapy, other than when given as an in-patient, indicated clinically and warranted due to hospitalization.
- Expenses incurred on Rotational Field Quantum Magnetic Resonance Therapy, Deep Brain Stimulation, Photodynamic therapy, High Intensity Focused Ultrasound, Balloon Sinoplasty, Enhanced External Counter Pulsation, Low-level laser therapy, Uterine Fibroid Therapy and related therapies, Embolisation, Chelation therapy, Hyperbaric Oxygen Therapy, VAX-D, and other such therapies similar to those mentioned herein.
- Deliberate injury to oneself.
- Expenses incurred on tonics and vitamins unless they are a part of the treatment and have been certified by the attending physician of the hospital where the treatment is being performed.
- Sexually Transmitted Diseases and Venereal Diseases.
- Expenses that come up due to any condition indirectly or directly caused due to or associated with Human T-cell Lympho Trophic Virus type III (HTLV-III) or Lymphadenopathy Associated Virus (LAV) or HIV / AIDS. However, it is being clarified that patients who are tested HIV positive (Human Immune Deficiency Virus) shall be eligible for expenses borne for treatment. Expenses for not allowed for opportunistic infections and for treatment of HIV/AIDS, given that during the initial start of coverage under this policy, their CD4 count is more than 350.
- Substance abuse, consumption of intoxicating substances, smoking, drugs/alcohol, and tobacco chewing.
- Treatment is arising from or traceable to family planning, pregnancy, miscarriage childbirth, abortion and complications due to any of these conditions (other than ectopic pregnancy).
- Treatment for Assisted Conception, Sub-Fertility, and or other associated complications caused due to the same conditions.
- Surgical or Medical treatment of the genetic and endocrine disorder and Sleep apnoea, Expenses incurred for Bariatric Surgery or weight management services comprising of surgical procedures for medical treatment of obesity.
- Medical conditions caused directly or indirectly or attributable to act of a foreign enemy, war, warlike operations or invasion, whether there is a war declaration or not).
- The run-down condition, Nutritional deficiency state, convalescence, rest cure or general debility.
- Experimental, Untested, Unproven and Unconventional therapies.
- Expenses incurred on Refractive Error Correction treatments such as Lasik Laser, treatment for disorders of eye requiring intravitreal injections and other related complications.
- Hospital registration charges, record charges, telephone charges, admission charges, or any other such charges.
- Chondrocyte Implantation, Intraarticular injection therapy, Stem cell Therapy, and Procedures using Platelet Rich Plasma
If any of the following conditions are present in you, then at the time of subscribing to the first insurance policy, these medical conditions will be considered as a pre-existing condition and shall be subject to a waiting period of 48 months before being covered under the policy are: -
- Diabetic Angiopathy;
- Diabetic Retinopathy;
- Diabetic Nephropathy;
- Diabetic Foot or Wound;
- Diabetic Ketoacidosis or Hyper Hypoglycaemia;
- Hypoglycemia; and
- Diabetic Neuropathy
During the first 30 days of a new health insurance plan, any expense incurred on account of medical issues, costs for hospitalization for any diseases, shall not be covered under the health insurance plan. However, this exclusion shall be overlooked or waived off when and if you have an existing medical policy with some other insurance company in India and have completed at least 12 months with the same insurance.
If the following conditions which are aggravated by hypertension are present in the insured person, at the time of subscribing to the first insurance by the insured person, will be considered as a pre-existing condition and shall be subject to a waiting period of 48 months before being covered: -
- Hypertensive Nephropathy;
- An aneurysm;
- Hypertensive Heart Disease such as Congestive Heart Failure(CHF) etc. or Coronary Artery Disease (CAD);
- Hypertensive Encephalopathy;
- Cerebro Vascular Attack; and
- Hypertensive Retinopathy
The treatments for erectile dysfunctions, sex-change operations, unnecessary cosmetic and aesthetic treatment of any sort, are excluded from the insurance.
If the following conditions are present in the insured person, at the time of subscribing to the first insurance with us, these will be considered as a pre-existing condition and will be subject to a compulsory waiting period of 48 months, before being covered under our your medical insurance: -
- Fistula in anus, Anal Sinus, Piles;
- Varicose Veins / Varicose Ulcers;
- Any type of Carcinoma / Sarcoma/ Blood Cancer;
- Surgical treatment for Tonsillitis/ Adenoids;
- Tympanoplasty / Septoplasty;
- All types of Ligament Meniscus Tears
Your medical expenses will not be covered by the insurance company during the first thirty days after the commencement of your policy, with us. However, this will only stand true for those insurance policies that are new, for older or those insurance policyholders with multiple policies with other insurance companies or for a period of more than 12 months, this waiting period will be waived off, and the claims will be processed as per the usual guidelines.
The list of hospitals listed and covered under our network is revised from time to time, and our list of blacklisted hospitals is updated regularly, which is why you should make it a point keep checking it from time to time. If you, as an insured person, go through some medical treatment at a hospital that is blacklisted or not covered by us, you may not get your medical claim in case of claims and cashless benefit cannot be availed unless the hospital falls under our network. It is recommended that you get in touch with our customer care by calling 1-800-103-5499 to know about your hospital.
If any of the following conditions are present in the insured person, during the time of subscribing to the first Mediclaim Policy with us, it shall be considered as a pre-existing condition and shall be subject to a compulsory waiting period of 48 months before being covered by the family health insurance:
- Cataract, Benign Prostatic Hypertrophy, DUB,
- Uterine Fibroids/PV Bleeding like Hysterectomy, Myomectamyetc;\
- A hernia, Hydrocele;
- Gall Bladder, Biliary, Renal and Urinary Stones;
- Knee replacement/Joint Replacement/Hip replacement (other than caused by accident);
- Any type of benign growth/Cyst/Nodules/Polyps/Tumour/Lump;
- Inter-vertebral Disc disorder like Spondylitis, Spondylosis, prolapse, etc. (other than caused by accident);
- Chronic Renal failure
The medical claim for the first insurance plan will not be processed during the initial 30 days. However, you will be entitled to coverage for medical bills, costs, and other expenses once the first 30 days elapse. Other than this, if you have medical insurance with any other Indian company, you can get your claims processed easily. Furthermore, it does not stand true for your renewed insurance policies.