Health Insurance Exclusions Explained: What Most Plans Don’t Cover
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 consider them either medically unnecessary or too expensive.
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Looking for health insurance? If so, your policy will likely have exclusions. It’s important to be aware of what most insurance policies don’t cover. In this Pacific Prime article, we’ll share more on health insurance exclusions and tips to manage them.
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 is a provision that eliminates coverage for certain treatments, conditions, and other items. Health insurance providers can choose to exclude any service they deem medically unnecessary, meaning details and conditions typically vary for each provider and selected policy.
To confirm, your health insurance plan documents should contain information about your plan’s exclusions.
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 disease or chronic conditions. Each provider may define pre-existing conditions differently and exclude coverage for them accordingly.
In some cases, your insurance provider may choose to cover pre-existing conditions, but it is often only under certain conditions, such as coverage starting 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 201,0 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 (ADHD) are often excluded from health insurance policies.
Treatments for these disorders may vary, but the costs involved from mental health specialists, medicines, and others often aren’t covered by insurance.
Psychiatric stays for these conditions may not be covered as well, depending on the provider and policy. While it is a common exclusion, some insurance companies have begun to offer more mental health care coverage.
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, separate plan, or only through higher-tier plans. 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.
International health insurance providers that offer fertility treatment in their more comprehensive plans are Allianz Care and VUMI. Read more about fertility 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. This exclusion even extends to acupuncture and chiropractic visits.
Coverage may vary depending on the insurance provider and location, as insurance policies in Eastern countries often provide 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 other means, including injuries procured after an attempt on one’s life, substance abuse, or 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 happens directly after an accident, injury, or illness and is considered reconstructive.
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 your main health insurance plan.
While routine dental care and orthodontic services are typically excluded, dental emergencies may be covered by your health insurance plan.
8. Obesity-Related Treatments
Health insurance providers often exclude weight-loss medications and other interventions for obesity, including weight-loss (bariatric) surgery, nutritional counseling, weight-loss equipment, and more. However, if your BMI is over 40, your insurance provider may cover weight-loss surgery.
Tips for Managing Health Insurance Exclusions
To deal with health insurance exclusions, consider purchasing supplemental insurance or researching alternatives to the excluded services. If you are excluded from coverage, you may have more options than you realize.
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 a supplemental plan helps extend your coverage and tailor your insurance to your needs. It gives policyholders flexibility and options while not forcing them to pay for coverage they do not require.
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 deal with health insurance exclusions is to look for covered alternatives to the treatments that are not included in your plan. If a specific medical service is denied, check whether there are other treatments that address the same condition and are still covered.
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 exclusions help insurers control costs and reduce financial risk. By not covering certain nonessential, experimental, or high-cost treatments, they limit unpredictable payouts. This allows them to price plans more accurately and keep premiums more affordable for policyholders.
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 them 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 the 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 them. 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. With Pacific Prime’s help, getting the right coverage for your needs doesn’t have to be complicated.
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.
Contact us today via our website to learn more, or call us toll-free at +1-800-868-1451!
With her background as an avid traveler and as an exchange student in Spain, Palida values the benefits of insurance and understands the frustrations that may come with making the best decisions for your health and safety in an unknown environment. Here at Pacific Prime, she aspires to create content that will help expats and travelers understand international health insurance with ease.
In her spare time, Palida enjoys reading short stories as much as binging on sitcoms. She is also a self-proclaimed "foodie" with the goal of trying as many cuisines from all over the world as possible. Combining her passion for writing with her love for food, she is an aspiring Google Local Guide reviewer.
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