Optima Restore is the stronger cover here.

Admissions And Charges Judged Unnecessary

The insurer can refuse an admission it judges was not medically needed - and, where the policy's own wording says so, any charge it judges above the going rate. It is the widest discretion in a policy and it applies to every claim, so keep the treating doctor's reasons on the file.

Anything Treatable Without Being Admitted

If the treatment could reasonably have been given without admitting you, the claim is refused - even though you were admitted. This is one of the most common reasons a hospital bill goes unpaid.

Birth Defects You Can See

Birth defects visible on the outside of the body are not paid for. The clause reaches only external conditions - internal birth defects are not excluded by it. Some policies apply a waiting period to an internal birth defect instead, so it is paid only after that period ends. The conditions quoted for each policy say whether that applies.

Conditions Excluded On Your Own Policy

Something can be written out of your cover for good, named on your own Policy Schedule when the policy is underwritten. Policies differ in how far that reaches: some can exclude only a disease that is declared and agreed to be excluded at the start, others any illness, injury, treatment or service the schedule names. The printed policy document does not list it, so read your schedule as soon as the policy is issued and ask the insurer to explain anything you do not recognise. Where a policy sets an end date for such an exclusion, or requires your written agreement to it, its own wording says so.

Dental Treatment

Ordinary dental work - check-ups, fillings, root canals, dentures - is usually not paid for. Serious dental treatment is paid only where the policy writes an exception of its own, so the exact trigger - an accident, a hospital admission, a named illness - sits in each policy's clause.

Expensive Drug Infusions

Expensive drug infusions, biologics most of all, are handled separately from ordinary hospital treatment. Some policies pay for them only when you are admitted, and refuse the same drug given in an outpatient infusion chair. Others refuse the admission that was arranged so that the infusion could be given, and a clause may name other costly infusions alongside, such as immunoglobulin or bone-strengthening drugs. Either way a large cost, often a repeated one, stays with you. The clause quoted for each policy tells you which way its own wording runs.

External Medical Devices

A device you can put on and take off yourself, without a surgery to fit it, counts as equipment rather than as treatment, and is not paid for. Each policy draws the line in its own words: some list the items, such as wheelchairs, walkers, crutches, glucometers, oxygen concentrators and machines for sleep apnoea, and others set a test, such as whether the device can be removed without surgery. Where a policy writes a way in, either inside the clause or through an add-on that names the items it will pay for, its own wording says so.

Glasses And Hearing Aids

Glasses, contact lenses and hearing aids are not paid for: they count as external aids rather than as treatment. Each policy groups them with the other corrective aids its own clause names, and some clauses reach further, as far as devices such as cochlear implants. Where a policy writes a way in, a device needed because of an illness or injury, one fitted during an operation, or an implant made necessary by an accident, its own clause says so.

Injections Into A Joint

Injections given into a joint, and the platelet-rich plasma and cartilage treatments offered for knee and joint pain, are excluded. Some clauses bar the treatment itself. Others bar only the admission that was arranged so that the injection could be given, and some reach wider, to an injection into a lesion or to the medicines infused alongside it. The clause quoted for each policy tells you which, and names the injections it means.

Circumcision

Self-Inflicted Injury

Treatment Abroad

Vaccinations

War And Nuclear Events

Cosmetic & elective

Aesthetic procedures, weight-loss surgery or hair transplants - unless medically required after an accident.

Self-inflicted injury

Treatment arising from intentional self-harm or reckless exposure to extreme risk.

Extreme adventure sports

Unlicensed skydiving, bungee jumping, deep-sea diving or professional motorsport.

War & nuclear risk

Injury from active participation in war, military operations, nuclear radiation or terrorism.

Maternity waiting limits

Standard waits (often 12–24 months) before pregnancy, childbirth and neonatal care are payable.

Addiction & rehab

Therapy for drug abuse, alcoholism, smoking cessation and long-term psychiatric care beyond stabilisation.