What are some standard health insurance policy exclusions?

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Asked April 1, 2013

1 Answer


All insurance plans, including health insurance, have limitations and exclusions. These are written into the policy to protect the insurance company against unnecessary or prohibitively expensive claims, and may be negotiable. If you are not able to negotiate the exclusions or limitations on your health plan, you may still be able to pick up a supplementary plan to fill in the gaps.

Typically, a health insurance plan will exclude some types of elective treatments, or treatments that may be necessary but are not life influencing. Here is a short list of possible exclusions, to give you an idea of the types of things that may be excluded:

  • Vision care and prescriptions
  • Dental care
  • Physical therapy
  • Fertility and artificial insemination
  • Substance abuse rehabilitation
  • Cosmetic surgery

Keep in mind that the list provided is an example. The exclusions and limits in your policy will almost certainly differ from this list, but it should serve to give you a good idea of what will and will not be covered. In addition to this list, any pre-existing conditions you have may be excluded from coverage. For instance, if you have diabetes, your policy may exclude some or all of the treatments and medications you need, or the policy may contain strict dollar limits on how much the policy will pay.

Usually any limitations related to medically necessary services such as pre-existing conditions will have a well-defined period of exclusion. Once that exclusion period has passed, your health plan will pick the bill on new costs. So you may not be able to get all of the treatment you need at first, but after a posted period of time it will begin to be covered. Furthermore, changes in health care law are making it easier for people with preexisting conditions to get coverage. By January of 2014, all group health plans will be required to accept preexisting conditions.

Even things which are not covered in the basic health insurance plan can be covered under a health insurance rider or supplementary insurance plan. You will have to pay the additional premiums, but you will not have to go without the medical care you need. For example, you can pick up a supplemental policy for your dental care, or add prescription coverage through a third party. Some types of supplemental coverages may be expensive though, as determined by the average cost of that type of care, your health, and other factors.

Answered April 1, 2013 by Anonymous

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