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Some of the most common health insurance exclusions include pre-existing conditions, cosmetic surgery, alternative medicine and therapies, and others. Many insurers choose not to cover these treatments because they don’t deem them as medically necessary or as too expensive.
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Looking to secure a health insurance plan? If so, chances are you’ll come across exclusions in your policy. Essentially, exclusions are what the plan won’t cover you for.
Before you dive right in to assess your policy or you use a broker like us to help you do so, it’s worth familiarizing yourself with the most common health insurance exclusions. In this Pacific Prime article, we’ll share more on this topic in the following sections.
Keep reading to learn about the most common health insurance exclusions, or click here to begin comparing plans from health insurance plans on your own.
Explaining Health Insurance Exclusions
An exclusion in a health insurance policy is a provision that eliminates coverage for certain treatments, conditions, and other items. Exclusions are not covered by the health insurance policy, and the details of these depend on the provider and the policy.
Health insurance providers can choose to exclude any service they determine as medically unnecessary. You can usually find out more about your plan exclusions in your health insurance plan documents.
Eight Common Health Insurance Exclusions
Eight common health insurance exclusions are:
- Pre-existing conditions
- Behavioral and personality disorders
- Fertility treatments
- Alternative medicine and therapies
- Self-inflicted and extreme sports injuries
- Cosmetic surgery
- Dental and vision coverage
- Lifestyle-related treatments
While there may be various reasons why insurers won’t cover these treatments or situations, each insurer may have different policies on these exclusions. When purchasing a health insurance plan, take the time to read the terms and conditions to determine what is covered and what isn’t.
We will share more about these exclusions and their details in the following sections.
1. Pre-existing Conditions
Pre-existing conditions are medical conditions that you have before getting health insurance, such as heart diseases or chronic conditions. Each provider may define pre-existing conditions differently, and many will exclude coverage for these conditions.
Your insurance provider may choose to cover pre-existing conditions but only under certain conditions. These conditions could be pre-existing condition coverage after a waiting period, or coverage offered only with higher premiums.
If you live in the United States, the Affordable Care Act (ACA) passed in 2010 makes it so insurers are legally unable to exclude coverage based on pre-existing conditions. This applies only to health insurance plans purchased through the ACA’s service, Marketplace.
2. Behavioral and Personality Disorders
Treatments for behavior and personality disorders such as borderline personality disorder, autism spectrum disorder, and attention deficit hyperactivity disorder are often excluded from health insurance policies.
Treatments for these disorders may vary, but the costs involved from mental health specialists and medicines and others often aren’t covered by insurance.
Psychiatric stays related to these ailments may not be covered as well, but it depends on the provider and policy. Some insurance providers have begun providing more mental health care coverage, but it still remains a common exclusion.
3. Maternity Coverage and Fertility Treatments
Health insurance companies commonly exclude maternity coverage and fertility treatments for women, with maternity coverage usually being offered as an optional rider or separate plan. Maternity services include prenatal and postnatal visits and childbirth.
Typically speaking, you won’t be able to get treatments like in vitro fertilization (IVF) and other assisted reproductive technology (ART) covered by health insurers. However, insurers in some countries may cover this if both partners are signed up or with a waiting period.
An international health insurance provider that offers IVF treatment in its more comprehensive plans is Allianz Care. Read more about IVF treatment coverage here:
4. Alternative Medicine and Therapies
Alternative medicine and therapies, such as homeopathy, naturopathy, reflexology, energy healing, and others may not be covered by your health insurance policy. Even acupuncture and chiropractic visits can be included under alternative medicine and therapies.
Coverage may vary depending on insurance provider and location, as insurance policies offered in Eastern countries often offer some coverage for Chinese traditional medicine treatments.
5. Self-Inflicted and Extreme Sports Injuries
Insurance providers may not cover injuries they determine as self-inflicted through extreme sports or through other means. This could include injuries procured after an attempt on one’s life, substance abuse, or through self-medicating without the help of a doctor.
Extreme sports can include skydiving, rock climbing, zip-lining, mountaineering, and other similar activities. Some health insurance policies offer optional extreme sports riders that can be added to cover these activities.
6. Cosmetic Surgery
Most insurance companies will not cover medically unnecessary procedures such as cosmetic surgery. Cosmetic surgeries and treatments are medical interventions done with the sole purpose of enhancing someone’s features aesthetically.
Common examples of cosmetic surgery and treatments not covered by insurance include:
- Abdominoplasty (also known as a tummy tuck)
- Liposuction
- Rhinoplasty (also known as a nose job)
- Botox injections
- Laser hair removal
Cosmetic surgery may be covered when it is considered reconstructive surgery and happens directly after an accident, injury, or illness.
7. Dental and Vision Coverage
Most basic health insurance plans do not cover dentist and optometrist visits for their policyholders. Dental and vision coverage often need to be purchased either as separate plans or as additional riders to be added to your main health insurance plan.
Emergency inpatient dental emergencies may be covered by your health insurance plan, but regular dental cleanings are often excluded. Orthodontic services are also usually excluded by health insurance plans.
8. Obesity-Related Treatments
Health insurance providers often exclude weight-loss medications and other interventions for obesity. This can include weight loss surgery, nutritional counseling, weight loss equipment, and more.
Weight loss surgery isn’t typically covered by health insurance, though if your BMI is over 40 your insurance provider may cover it.
Tips for Managing Health Insurance Exclusions
To manage health insurance exclusions, you can try purchasing supplemental insurance or research alternatives for the excluded services. If you are being excluded from coverage, you may have more options available than you think.
Purchase Supplemental Insurance
Certain health insurance exclusions like dental, vision, and maternity coverage can typically be purchased through supplemental insurance. These can come in the form of optional riders that can be added to basic health insurance plans or through separate insurance plans.
Adding this supplemental health insurance can further extend your coverage and tailor your insurance to your needs. It offers flexibility and options to policyholders and won’t make them pay for coverage they don’t need.
If you’re interested in looking at supplemental health insurance offered by top insurance providers, reach out to Pacific Prime for advice or a free quote.
Research Alternatives for the Excluded Services
Another way to manage health insurance exclusions is to research alternatives for the excluded treatments to see if you can find treatments that are covered. If you are being denied coverage for one medical service, see if there are other covered services that are just as viable.
For example, if you are interested in trying homeopathic services but are being denied coverage, see if you can find a reasonable alternative. Perhaps your insurance will cover acupuncture or another more holistic option.
Frequently Asked Questions
What are some of the most frequent health insurance exclusions?
Some of the most frequent health insurance exclusions are pre-existing conditions, behavioral and personality disorders, fertility treatments, alternative medicines, self-inflicted injuries, cosmetic surgery, dental and vision coverage, and obesity treatments.
Why do health insurance companies have exclusions?
Health insurance companies have exclusions in care in order to keep premiums low and to mitigate their risk of insuring the policyholder. By limiting what they determine to be medically unnecessary, policyholders can keep their premiums more affordable.
Can I get my pre-existing condition covered by my insurance?
While many health insurance providers do not cover pre-existing conditions, you may be able to get it covered through a higher premium or after a waiting period. If you are a U.S. citizen, you can receive coverage for your condition by purchasing a health insurance plan through Marketplace.
Are cosmetic procedures ever covered by health insurance?
Typically cosmetic procedures aren’t covered by health insurance because they are not medically necessary, but there may be special circumstances where the insurance company covers it. These circumstances may include reconstructive surgery after an accident or injury.
Conclusion
Understanding common health insurance exclusions can help you better understand your coverage when you purchase your health insurance policy. Getting the right coverage for your needs doesn’t have to be complicated with Pacific Prime’s help.
Our expert advisors are also only one phone call or email away if you’d like to discuss your health insurance options. As each individual and situation is unique, our advisors provide you with unbiased insurance consultation and offer a no-obligation quote.
We have years of experience in providing insurance options to clients across the globe and can simplify your health insurance shopping experience. Contact us today via our website to learn more, or call us toll-free at 1-800-868-1451!
With over 5 years of experience in the field, Suphanida spends the majority of her day synthesizing complex pieces of insurance-related information and translating this into easy-to-understand, engaging, and effective content across a variety of media such as articles, infographics, whitepapers, videos, and more.
Suphanida is also responsible for planning and publishing three whitepapers released annually by Pacific Prime: The State of Health Insurance Report, The Cost of Health Insurance Report, and The Global Employee Benefits Trends Report. Additionally, she handles the LinkedIn profiles of Pacific Prime’s Founder and CEO, as well as Global HR Lead.
Suphanida’s strengths lie in her strong research and analytical skills, which she has gained from her BA in Politics from the University of Warwick and Erasmus Mundus Joint MA in Journalism from Aarhus University and City, University of London.
Being of Thai-Indian origin and having lived, studied, and worked in Thailand, the UK, and Denmark, Suphanida also has a unique, multicultural perspective that helps her understand the struggles of expats and globetrotters.
Outside of work, she enjoys traveling to new places and immersing herself in different cultures.
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