Permanent exclusions in health insurance are specific medical conditions, treatments, or situations that are clearly defined in the policy as never being covered, regardless of when or how they occur. These exclusions are set by the insurer and remain in effect throughout the life of the policy, meaning that any expenses related to them will always be the responsibility of the insured. Common examples include cosmetic surgeries, congenital diseases, or injuries caused by substance abuse.
Contents
Exclusions
- Expenses for higher-category rooms such as Deluxe or Suite are not covered.
- Medical treatment outside Nepal is not covered under this policy.
- Specified illnesses (e.g., kidney stones, cataract) have a 2-year waiting period before coverage begins. (Link of detail list).
- Maternity-related treatments, including miscarriage, abortion, and premature childbirth, are excluded.
- Pre-existing conditions are covered only after 4 years of continuous enrollment.
Exclusions
- Suicide, attempted suicide or self-inflicted injury.
- Committing or trying to commit criminal activity or participate in any unrest or brawl (All forms of judicial cases).
- War, invasion, acts of foreign hostility, aggression (whether the war is declared or not), rebellion, armed revolt, acts of terrorism and also due to civil commotions.
- Dangerous sports such as motor racing, climbing, or motor cycle racing of any kind etc.
- All cases to addiction of alcohol or drugs and all products that cause hallucination.
- Nuclear fission or fusion, automatic radioactive pollution, and chemical and biological toxicants.
- All undeclared pre-existing cases (For non PED policies/ waiting period for PED policies)
- Paraplegia, , AIDS and related treatment, hemiplegia, Alzheimer, and mental disorders, STD.
- Plastic surgeries and cosmetic treatments unless, it was the result of a covered accident that took place while the insurance cover were in effect.
- Acne, freckles, loss of hair.
- Quarantine, venereal diseases, sterility telemedicine and everything related to fertility.
- Cases of hearing and sight correction, instruments of hearing and sight unless due to accident covered by the insurance policy.
- Dentistry and oral surgery, bridgework denture, crowns and all related work, unless it was the result of an accident which took place while the insurance is in effect.
- Medical and psychological disorders (Mental and Psychiatric disorders) sedatives and mental medicines, epilepsy, congenital and genetic disease and astigmatism.
- Placement of artificial limbs and implementation of any instrument in the human body and the medical assistance instruments such as artificial knee, heart stimulator … etc and all other instruments.
- General epidemics and contagious diseases, Sars, and all diseases covered by the state.
- Any in hospital treatment or the diagnostic tests and any medical tests that can be performed outside the hospital without endangering the health of the assured.
- Sight and Dental benefits unless mentioned in the schedule of benefits.
- All substances that are considered as food stuff.
- Congenital diseases/ disorders are permanently excluded
Named Surgeries – 2 years waiting period
- Cataract*
- Benign Prostatic Hypertrophy
- Myomectomy, Hysterectomy unless because of malignancy
- Fissures &/or Fistula in anus, hemorrhoids/piles
- Arthritis, gout, rheumatism and spinal disorders
- Joint replacements unless due to accident
- Sinusitis and related disorders
- Stones in the urinary and billiary systems
- Dilatation and curettage , Endometriosis
- All types of Skin and internal tumors/ cysts/nodules/ polyps of any kind includingbreast lumps unless malignant
- Dialysis required for chronic renal failure
- Surgery on tonsils, adenoids and sinuses
- Gastric and Duodenal erosions & ulcers
- Deviated Nasal Septum
- Varicose Veins/ Varicose Ulcers
- Per Eye cataract sublimit of NPR 20,000
4 Years Waiting Period
Any pre existing illness shall be excluded for a period of 4 consecutive years immediately preceding the period of insurance (i.e. Diabetes, heart condition(HTN) , thyroid, etc)
Others:
- Medical expenses incurred within 30 days of inception of the policy.
- Non-medical expenses (i.e. Sanitary napkins, towels, tooth brush, birth certificate, thermometers, etc.)
- Ambulance charges.
- Higher category room (i.e. suites), however this does not apply to single standard AC rooms / cabins).
- Covid-infection control charge.
Covid 19 Exclusions:
- Covid-infection control charge
- Food Expenses
- PPE kit
- Pulse oximeter
- Thermometer
- Gloves
- Masks