Common Exclusions



Exclusions range from elective surgical procedures (things like LASIK and cosmetic surgery) to coverage for specific diseases that require long-term care. Here are a few common exclusions:

Pre-existing Conditions. This is one of the most common insurance policy exclusions, and it encompasses any condition for which you may have received medical care prior to the first day of coverage under a new plan. One of the ways your new insurance will cover you for these is if you were previously covered - this is why when you leave a company where you had benefits, your documentation always includes a "proof of coverage" certificate. In some cases, pre-existing conditions will be covered, but only after a waiting period of up to a year.

Elective Surgery. While elective surgery includes everything from a facelift to lap-band surgery for weight loss, and is almost never covered, there are some exceptions. Breast reconstruction after a mastectomy is generally covered, though you and your doctor may have to fight for it. Breast reduction surgery is often covered if having it will ease severe back pain, but only after other treatments have been attempted. Bariatric surgery (for weight loss) is usually excluded, but if your doctor can show a history of nutritional counseling and exercise, and you are morbidly obese, you can often get this covered. LASIK is generally not covered by medical insurance, but a separate vision insurance policy may pay for part of it, if you are no longer able to have your vision corrected by conventional means.

Hospital Stays. Time in the hospital is generally built into your insurance policy, but certain convenience features, like using the in-room telephone or television are often excluded. Hospital fees are generally extremely high, so check with your insurance company before you find yourself checked in.

Home Health Aids and Private Nursing. These are generally not covered. The Centers for Disease Control says that more than 1.4 million patients use home health care, with the average length of treatment being about 60 days. These costs can add up very quickly, so research other options - hospice care, and other volunteer organizations.

Learning Disabilities and Behavioral Problems. Because these are often classified as psychiatric issues, rather than medical, conditions like dyslexia and ADHD that require ongoing treatment are often excluded from health insurance coverage, though as information is added to medical databases, this is changing. Many policies now cover the medication for these conditions, if not the alternative treatments.

Alternative Therapies. Insurance companies are designed to deal with traditional Western-style medicine - doctors and pills - and often won't cover alternative treatments methods, which include chiropractic treatment, acupuncture, acupressure, and biofeedback - even when these treatments are used to complement conventional procedures.

Dental and Vision Care. Most insurance plans don't offer dental or vision coverage, and most corporate benefit packages offer separate dental and vision plans, however, if a dental or vision issue is the result of an accident, or another medical issue, your regular health coverage may apply.

If this list of exclusions makes you wonder why you have insurance at all, consider that most insurance does cover preventative medicine, treatment for common ailments, and general health issues, and that seeing your doctor regularly may help you stay healthy enough to never need excluded coverage.

It should also send you to your file drawer, to examine your policy, because knowing what is and is not covered is often more crucial than having coverage, and there are ways to offset the cost of excluded procedures, like instituting a flexible spending account, or taking out a supplementary life insurance policy.