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Health Insurance Policy Exclusions

One of the best ways to evaluate a health plan is to take a good look at what it doesn't cover. Exclusions are the health care services not covered by your policy, and a cheap health insurance plan might carry too many of them. Here's what to look for.


This page:

  Identifies the exclusions in the average health insurance policy

  Reveals some hidden exclusions often implied in a plan

  Provides an easy way to compare different plans' exclusions


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Do You Qualify For A Subsidy?


Find out if you qualify for a government subsidy under Obamacare. Millions of Americans will have their insurance rates reduced under the new health care law. Learn how much you could save with our simple calculator.

Exclusions in your policy's benefits section

Start by reading over the benefits section and writing down any health care service that is not covered by your health insurance policy. These are a few of your health insurance exclusions.

Exclusions in your policy's definitions section

Next, locate the definitions page of your health insurance policy. Often, health insurance companies hide coverage exclusions within their definitions of words.

The way your health insurance company defines a certain word may be quite different than the common definition.

For instance, you may define the term "emergency" as anything that requires instant medical attention, while your health insurance policy may define it as "a life threatening condition that cannot be reasonably treated by your primary care physician." Using this definition, the health insurance company can deny coverage for emergency room treatment of a broken arm on the grounds that a broken arm is not life threatening and you can, therefore, wait until you primary care physician gets off the golf course to treat it.

This is an extreme example, but a good illustration of how a coverage exclusion can be hidden in a definition.

We advise you to read over the health insurance policy definitions, paying close attention to these seven key words:

  medical emergency
  medically necessary
  accidental injury
  experimental or investigational
  pre-certification
  pre-existing condition, and
  reasonable and customary.

These words and any words that are open to interpretation should be regarded with wariness. Find out how your health insurance company defines each of these. What health care services are experimental? What is considered an emergency? These are definitely some of the questions you will want to ask.

Exclusions in your policy's conditions section

Finally, find the section describing the procedures you must follow in order for your health insurance company to reimburse you. These policy conditions or prerequisites are typically worded in a positive tone.

For instance, a policy may state that your primary care physician will be responsible for arranging all your health care needs, making referrals, and approving health care treatment. However, this may mean emergency medical services without a pre-approval from your primary care physician will not be covered by your insurance company.

Read through each condition carefully, make notes and call your health insurance company with any questions.

Comparing policy exclusions

The easiest way to compare exclusions, is to take two policy contracts, find the exclusions sections, and start reading.

But what are the odds that you'll be able to get your hands on all the contracts for policies that you are interested in?

The next easiest way is to use an online service such as eHealthInsurance. After you obtain your free quote for the health coverage you desire, apply for it online, and you'll obtain all the information that you'll need to compare exclusions in the policy (though sometimes this will take a little digging.)

If you'd rather receive personal help when deciphering exclusion provisions, fill out a free quote request form at NetQuote. They will put you in touch with independent agents in your area who will help you further.


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This internet site provides information of a general nature for educational purposes only and is not intended to be legal advice. We make no guarantees as to the validity of the information presented. Your particular facts and circumstances, and changes in the law, must be considered when applying insurance law. You should always consult with a competent insurance professional licensed in your state with respect to your particular situation.