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Health Insurance Policy Exclusions & Restrictions

Instructor: Elisha Madison

Elisha is a writer, editor, and aspiring novelist. She has a Master's degree in Ancient Celtic History & Mythology and another Masters in Museum Studies.

Health insurance exclusions and restrictions create the guidelines for what will and what will not be covered in a policy. The following are some of the standard and unique exclusions and restrictions for health insurance policies.

Introduction

Medical coverage is important. We all have moments, whether we get sick or we fall off a curb and break something, when we are reminded of how essential it is to have help to pay our medical bills.

Health insurance policies are contracts between an insurer and insured. These non-tangible products provides payment for medical services, such as hospital visits and medication. However, there are both standard and unique lists of exclusions and restrictions that every insured is made aware of when they elect their coverage.

Exclusions

  • Alternative Medicine - This exclusion means that an insured will not be covered if using medical options such as acupuncture, acupressure, massage therapy, and even chiropractic care. This can be a restriction or an outright exclusion, depending on the insurance company.
  • Cosmetic - This exclusion denies insurance benefits for cosmetic procedures, such as liposuction or breast enhancements. However, breast reductions can be paid for if they are proven to be medically necessary. Tummy tucks have also been known to be paid for if the skin is causing a medical issue. This exclusion also restricts insurance payouts for gender reassignment surgery.
  • Weight Loss - This is another exclusion that keeps an insured from receiving reimbursement for liposuction, but it can also stop a bariatric surgery from being covered, unless it is required to save the insured's life due to another life-threatening health concern, such as a heart condition.
  • Infertility Treatments- This keeps the insured from receiving money to pay for treatments for infertility, even if the infertility is due to a medical issue. This exclusion is not as popular now, though, and some insurance companies have been known to cover these treatments.
  • Dental and Vision - Regular medical coverage will not pay for most dental or vision needs, such as cleanings or vision tests. However, if a dental or vision need crosses over to the medical realm, such as a jaw issue that is causing severe migraines and blindness, medical insurance can be convinced to pay for this. Medical coverage generally does not include dental and vision benefits due to the fact that there are separate, individual policies that cover these.
  • Experimental - Medical treatments that are considered risky and experimental may not be covered under an insurance plan. New treatments for cancer or medical testing could be denied.

Some unique exclusions stop medical coverage for:

  • War Injuries - These are injuries that happened during war, whether to a soldier or civilian.
  • Self-inflicted Injuries - These can include suicide attempts, self-scarring, or even bulimia or anorexia. The exclusion for suicide is less likely now, however, if it can be proven that the insured had a mental-health issue that caused the suicide or attempted suicide.
  • Injuries Suffered While Committing a Criminal Act - This refers to a criminal who is in the midst of a criminal act and is hurt. For example, someone who breaks your house window, climbs in to to steal your things, and cuts themselves on the broken glass would not be able to have the injury covered by insurance.

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