Health Insurance Exclusions and Other Restrictions on Coverage

Posted September 3, 2013 | Filed under topic Health Insurance Information

Compared to other kinds of big purchases like buying a car or a home, health insurance is one of the items that buyers may not really understand very well. A shocking number of enrolled members of health insurance companies don’t understand their policies in detail, and are unpleasantly surprised when they encounter challenges with claim payments.

One of the big issues that consumers need to know about when choosing health insurance is the issue of policy exclusions. Exclusions are how the insurance company refers to services that are never covered or not commonly covered under a plan. The problem is that these may not be fully described to insurance shoppers, especially for group policies, where sign-ups are fairly independent and there’s not a very close link between the insurance company and the customer.

Pre-Existing Condition Exclusions

One of the most common exclusions in a health insurance policy involves pre-existing conditions. Many of us have heard of pre-existing condition denials, but may not fully understand our own policies until there is a claim denial or other problem. Many insurance companies will refuse to cover a range of pre-existing conditions, or require the person to be enrolled for a long time before starting to cover any care related to these conditions.

Dental and Vision Exclusions

In terms of common healthcare exclusions, these are some of the non-covered services that consumers tend to know about. Many of us understand that even the best group policies are not likely to cover any kind of dental care or vision care, which is why individuals by these policies separately. It’s also relatively common knowledge that cosmetic surgery or other “elective” services are not usually covered. However, another kind of exclusion can be more of a problem, and those with insurance should always check on coverage for mental health services for conditions like autism, depression, etc.

Maternity and Prescription Exclusions

Another kind of exclusion revolves around women’s healthcare. Maternity exclusions may limit coverage for services related to birth. This can push a lot of the costs onto patients, since even a routine birth and to being extremely expensive in many hospitals.

Prescription exclusions can also cause a lot of problems for patients. Doctor visits may be covered, but when they visit the pharmacy, they may find they have to pay full price out of pocket for prescriptions, which can cost many hundreds of dollars each month, depending on the drug in question.

In addition to these, health insurance companies will often add exclusions for alternative or non-typical kinds of medical care such as massage, acupuncture or chiropractic care.

Effects of Healthcare Reform

Health insurance exclusions are one of the items that the Affordable Care Act is intended to address. Information coming out on healthcare reform shows that the Affordable Care Act is likely to require insurance companies to cover pre-existing conditions, as well as dental and vision care for children and other vital family services that had not been commonly covered under prior independent insurance policies.

Knowing about how insurance companies structure their policies can help a family to negotiate and get the best kinds of coverage and the best rates. Look carefully at how a company adds exclusions and limitation to know what you are getting for your money.