Health Insurance won`t Cover These 10 Things In Nepal 2025
Buying health insurance in Nepal is becoming increasingly common, especially with rising medical costs in private hospitals. But here’s something many people don’t realize: just because you have health insurance doesn’t mean everything is covered!
Insurance policies come with “exclusions” — the fine print that lists what’s NOT covered. Understanding these exclusions can save you from unpleasant surprises during medical emergencies.
So, before you happily sign that insurance document, let’s uncover the common exclusions found in health insurance policies in Nepal — explained simply, for everyday families, students, workers, and retirees.
What Are Health Insurance Exclusions?
In simple words, exclusions are medical situations, conditions, or expenses that your insurance company won’t pay for.
For example:
Your health insurance may cover hospital stays — but not dental treatment or plastic surgery.
Not knowing these details can lead to claim rejections, which can be very frustrating during emergencies.
Real Story: Mina from Pokhara
Mina, a teacher in Pokhara, got a health insurance policy and later had to undergo dental surgery worth NPR 40,000. She thought her insurance would cover it. But later, she discovered that dental treatment wasn’t covered, and she had to pay the entire amount from her savings.
Moral of the story? Always know what’s excluded!
Top 10 Common Exclusions in Health Insurance Policies in Nepal
1. Pre-Existing Diseases (Within the Waiting Period)
If you already have diseases like diabetes, high blood pressure, or asthma before buying insurance, the company usually imposes a waiting period (commonly 2–4 years) before covering these conditions.
2. Maternity and Newborn Expenses
Most basic plans do not cover pregnancy, childbirth, or newborn care unless explicitly included. Even if included, it comes with conditions like 2 years of continuous coverage before you can claim maternity benefits.
3. Cosmetic and Plastic Surgeries
Want to get a nose job or remove a scar for beauty purposes? Not covered. Only reconstructive surgeries after accidents may be considered.
4. Dental and Vision Treatment
Routine dental checkups, braces, glasses, and eye surgeries like LASIK are generally not covered unless due to an accident or as part of a special plan.
5. Self-Inflicted Injuries and Substance Abuse
Injuries caused due to suicide attempts, drug overdose, or alcohol-related accidents are not eligible for insurance claims.
6. Non-Allopathic Treatments (Like Ayurvedic or Homeopathic)
Some insurance companies only cover allopathic (Western medicine). So, if you go for Ayurvedic or homeopathic treatments, especially outside registered hospitals, they may not pay.
7. Experimental or Unproven Treatments
New, unproven therapies or clinical trials are not covered. Your insurer will pay only for treatments approved by national or international medical guidelines.
8. HIV/AIDS and Sexually Transmitted Diseases
In many policies, treatment for HIV/AIDS, STDs, or venereal diseases is not covered unless stated otherwise.
9. War, Terrorism, and Nuclear Exposure
Injuries due to war, riots, terrorist attacks, or nuclear accidents are typically excluded, as they are considered high-risk scenarios beyond standard coverage.
10. Alternative and Unlisted Hospitals
Getting treatment in a hospital that’s not in the insurer’s network list can lead to rejection of claims, especially for cashless services. Always check the hospital list before admission.
Other Hidden or Lesser-Known Exclusions
· Waiting Periods: Most policies have a 30-day general waiting period after purchase (except for accidental injuries).
· Ambulance Charges: Not all plans cover full ambulance costs — some have a cap (e.g., NPR 2,000).
· Daycare Procedures: Only specific surgeries like cataract, dialysis, etc., are allowed under daycare procedures.
· Diagnostic Tests Without Admission: If you do tests like X-rays or MRIs but don’t get hospitalized, the insurance might not pay.
How to Avoid Claim Rejections?
✅ Read the Policy Document Carefully
Even if it’s boring, go through it. Or ask your insurance agent to explain every clause in simple Nepali.
✅ Ask About Inclusions and Exclusions Clearly
Don’t be shy. Ask, “Will this plan cover dental, pregnancy, or pre-existing diseases?”
✅ Keep Medical Records Handy
During claims, you’ll need doctor’s prescriptions, bills, diagnostic reports, and discharge summaries.
✅ Stick to Network Hospitals
Always go to hospitals listed under your insurance provider to ensure smoother claims.
Final Thoughts
In Nepal, more people are wisely turning to health insurance for medical protection. But the truth is — a policy is only as good as what it actually covers.
Understanding exclusions is the key to using your insurance effectively and confidently. Don’t be afraid of the fine print — instead, make it your friend. It could save you thousands of rupees and a lot of stress.
Remember: Insurance is a shield, but only if you know where the holes are.
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