General Debility, STD, Alcoholism and Suicide
Convalescence, general debility, run-down condition or rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury, and use of intoxication drugs/alcohol.
Under this clause hospitalization for recovery, convalescence, general debility or run-down condition are not eligible for reimbursement.
Hospitalization with extended hospital stay without proper justification or reasoning is liable for repudiation. For example after a surgery or caesarian section, keeping a patient hospitalized for 7 days (or more) for the purpose of removal of sutures is liable to attract repudiation of the claim. Removal of sutures varies based on the surgery and can be carried out even after the patient is discharged from the hospital, wherein further or continuous medical attention is not required.
A classic example being followed by some Ayurvedic hospitals or Ayurvedic resorts makes it binding on patients to undergo 7, 14, 21, 35 or 42 day package for their ailments. Extended hospital stay without proper justification but with ample validation of proof does not qualify for reimbursement. Such treatments can be availed on OPD basis as practiced in other parts of India (Some Ayurvedic hospitals may try to dispute this stand, but proof exists that patients have been cured of their-ailments with testimonial of Vaidyas or Ayurveda Physicians from all over India, but there is lack of enthusiasm in documentation of data. Other point is the non-disclosure of treatment details (mainly because of secrecy in treatment) with other Ayurveda physicians or medical fraternity).
Similarly hospitalization sought for rest purpose does not qualify for reimbursement, for example, after-shocks on account of RTA without any body injury, admission of an aged person in the hospital for medical check-up and rest, flatulence etc.
Treatments performed at Health Resorts or Spas or Hotels or Holiday Homes falls under the category of rest-cure.
Congenital External Diseases such as Cleft Palate, Birth Mark, Lipoma, Phimosis, Squint, Flat Feet, Bow Legs etc. are not reimbursable by Insurance.
Under this clause, venereal diseases such as STD (Sexually Transmitted Diseases), Syphilis, Gonorrhea, HIV, AIDS etc. are not reimbursable by Insurance.
Sterility procedures such as Tubectomy in males and Vasectomy in females are not reimbursable by Insurance. Insertion of IUCD (Intra-Uterine Contraceptive Device) for family planning purposes or spacing of births is not reimbursable by Insurance.
Intentional self-injury is also not reimbursable by Insurance under this clause. Instances of self-injury include consumption of poison, knowingly or unknowingly, consumption of sleeping tablets, creating injury marks on the body with the help of a knife or any other sharp instrument, unsuccessful suicide attempt by an individual etc. are incorporated under this clause.
Usage of intoxicants, intoxicating drugs and consumption of alcohol are also included under this clause. Intoxicants include sedatives and tranquilizers, consumption of poisonous plants such as bhang, opium etc. are excluded from the purview of reimbursement by Insurance companies, Consumption of brown sugar, hashish, charas, ganja, gutkha, zarda etc. and its after-effects are denied reimbursement by Insurance companies.
Diseases occurring on account of alcoholism are denied reimbursement. Alcoholism is another type of intoxication. Diseases or ailments such as RTA (Road Traffic Accident), Liver cirrhosis, Acute Pancreatitis, Chronic Pancreatitis, Liver Abscess etc., diseases when under the influence of alcoholism are denied the benefit of reimbursement by Insurance companies.
