Understandably, it would be impossible to find a health
insurance policy that covers every illness or medical condition without limits
or exclusions. Most policies specify certain types of injuries, illnesses, or
procedures for which they provide a lower level of coverage. Furthermore,
certain illnesses, injuries, and procedures may not be covered at all.
Limitations are conditions or procedures covered under a policy but at a benefit
level lower than the norm. Exclusions, on the other hand, are conditions or
procedures that are completely omitted from coverage. Your health insurance
policy should list all limitations and exclusions. Therefore reading and
understanding one's health policy is certainly an important thing to do.
What are some common limitations and exclusions?
Although the specifics of limitations and exclusions do vary from policy to
policy, the following is a list of common limitations and exclusions a standard
policy might include:
- Pre-existing conditions: A pre-existing condition is
an illness or injury that began or occurred before you obtained coverage
under a policy. Pre-existing conditions are often excluded from coverage, or
may be covered after a specified waiting period.
- Nonduplication of payments/coordination of benefits:
In order to prevent double coverage, many policies specify that benefits
will not be paid for amounts that are reimbursed by other insurance
companies. This provision limits the total payment of benefits to 100% of
covered expenses.
- Alcohol and/or drug abuse treatment
- Care covered by the Veterans Administration or workers'
compensation
- Cosmetic surgery: Cosmetic surgery required as the
result of an accidental injury or congenital defect is generally not
excluded.
- Dental expense: Some policies may cover
reconstructive dental treatment resulting from accidental injury.
- Experimental procedures
- Hernia
- Infertility treatment
- Injury incurred while committing a felony
- Injury, illness, or death that occurs while under the
influence of intoxicants or narcotics
- Military duty: This provision usually suspends the
policy while the insured is serving in the military.
- Noncommercial airline travel
- Organ transplants
- Self-inflicted injuries
- STDs
- Vision correction
- War or acts of war that result in injury or death
What is a rider?
Insurance policies are usually written in a standard form, most of which is
dictated by state insurance law. If you need additional coverage or if there are
changes to the standard document, these changes can be made by way of a rider.
The information to be conveyed in the rider is typed up on a separate piece of
paper, which is attached to the standard policy. An endorsement can accomplish
the same goal; the only difference is that an endorsement is actually
incorporated into the body of the existing policy. Some common health insurance
riders are as follows.
Multiple indemnity
In some health insurance policies, accidental death or dismemberment benefits
may be doubled or tripled depending on the cause of death or specific type of
dismemberment. This multiple indemnity may be included in the policy by way of a
rider.
Waiver of premium
Some policies may allow you to skip premiums during periods of extended
hospitalization.
Exclusion
Also called an "Impairment rider," this rider is used to specify a
medical condition that might normally be covered but is not covered because it
is a pre-existing condition. Although the particular condition is not covered,
use of this rider allows the applicant to obtain insurance for other healthcare
needs when this condition might otherwise make the person uninsurable.
Additional
coverage
If the insurer agrees to provide
coverage that is not included
in the standard insurance
contract, this coverage might
be described in a rider.
