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Insurance Exclusions

        Health | Health Insurance

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Many of us assume that if you have health insurance, your health care costs are either covered or at least partially paid. Unfortunately, this is not always the case -- this is where health insurance exclusions come into play. A health insurance exclusion refers to anything the insurance company will not cover, ranging from a type of drug to a type of surgery. These exclusions can vary from plan to plan, and it's essential that you get to know your plan's exclusions.

Common Health Care Exclusions

The subject of pre-existing conditions is always a hot one. A pre-existing condition is a condition for which you have received medical care before the first day of coverage on a new plan. Legislative changes in the past decade have made it easier for those with pre-existing conditions to receive health care. However, many plans still have waiting periods for people with pre-existing conditions.

One of the main types of exclusions comes up with hospital stays. Use of the hospital room phone or TV, extra pillows and sometimes even Band-Aids are commonly excluded from insurance coverage. Hospital fees can be high, so it's important to be familiar with your plan's exclusions.

Home care and private nursing expenses are some of the most common excluded expenses. According to the Centers for Disease Control, more than 1.4 million patients using home health care, with the average patient needing at least 60 days of treatment [source: CDC]. Without any coverage, these health care expenses can add up fast.

One surprise may be the exclusion of coverage for patients with behavioral or learning problems, like dyslexia and ADHD. These are commonly excluded because these conditions usually require care that can last for several years. However, recent awareness of these conditions, especially ADHD, has caused many plans to only partially exclude them and cover many of the drugs needed to manage these conditions.

Not surprisingly, cosmetic surgeries are often not covered. These surgeries include elective nose jobs, face lifts, tummy tucks and the like. However, some cosmetic surgeries -- those done in response to a medical problem -- are usually covered. These surgeries usually include breast reconstruction after a mastectomy, a nose job to fix a deviated septum and skin grafts for burn patients. Recently, insurance companies have started to consider circumcisions elective because their health benefits are under question. Sex-change surgery isn't often covered because most plans don't consider it medically necessary. Abortion is also generally excluded because the political impact of including the procedure could outweigh the health consequences of excluding it.

Alternative and complementary medicine is often not covered by health insurance. Alternative medicine is used in place of conventional medicine, and complementary medicine is defined as treatments and procedures that are used together with conventional medicine. These types of medicine include acupuncture, acupressure, yoga, massage and biofeedback.

Finally, most health insurance plans do not include dental or vision care. These services are included in separate policies. However, many plans will cover dental or vision care that is required because of an accidental injury. Therefore, be sure to check with your insurance company before paying out of pocket for that chipped tooth.

Your plan may exclude more than this basic list, so check and double-check your list. You might find that some drug benefits are excluded. In the next section, we'll discuss the most common drug exclusions.