Sick while pregnant? Why insurance companies might dispute your claim and what you can do about it

Pregnancy and related medical expenses are generally not covered under standard health insurance policies unless the plan includes maternity benefits or the policyholder has opted for a maternity add-on or rider.

As pregnancy typically lasts around nine months, a woman may need treatment for illnesses unrelated to pregnancy despite taking all necessary precautions. However, determining whether the ailment requiring hospitalisation is connected to pregnancy can sometimes be a grey area, potentially resulting in disputes between insurers and policyholders.

For instance, in one case, a woman underwent treatment for a gastrointestinal infection while she was pregnant.

At the same time, she was diagnosed with severe hyperemesis gravidarum, a pregnancy-related condition characterised by intense nausea and vomiting. The insurer rejected her hospitalisation claim, citing the exclusion of pregnancy-related complications in her policy. The woman had a regular health insurance plan without maternity coverage.

The expenses would generally have been payable if the policy had included maternity benefits, either as part of the base policy or through a rider.

Experts said insurers rely on panels of specialist doctors to assess whether such claims are admissible under the terms and conditions of a policy.

For example, an ophthalmologist could identify an eye infection during a cataract procedure. Cataract treatment may not be covered during the initial waiting period, which can range from six months to two years depending on the insurer and product variant.

Policyholders should also note that the Insurance Regulatory and Development Authority of India (IRDAI) has directed insurers not to contest claims or policies after 60 months of continuous coverage on grounds of non-disclosure, except where fraud has been established.

One aspect is relatively clear: insurers generally do not cover complications arising directly from a disease, procedure or treatment that is excluded under the policy.

If the primary medical condition or procedure is specifically excluded, any complications, side effects or treatments that can be traced back to that excluded condition may also be denied, experts said.

Pregnancy, for instance, is generally excluded from regular retail health insurance policies. Even plans offering maternity benefits may impose a waiting period of up to three years before such expenses become payable.

Similarly, certain procedures, including cataract and hernia surgery, may be covered only after waiting periods of up to two years. Cosmetic and dental treatments, meanwhile, are generally permanently excluded under standard health insurance policies.

Experts said that when an excluded medical condition overlaps with another ailment, there is a high possibility that the related insurance claim could be rejected.

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