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Limitations and Exclusions In Health Insurance

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Limitations and Exclusions In Health Insurance

Limitations and Exclusions In Health Insurance

There are certain restrictions in the coverage provided by the health insurance companies. The health insurance policy of an individual contains a list of medical needs that do not come under the coverage or with very little coverage. The limitations and exclusions in health insurance that are commonly seen are different with respect to the policies taken and make it important to read carefully the actual policy before going in for a particular choice.

Limitations and Exclusions in Health Insurance Policy

Pre-existing conditions in health Plans

In most of the health plans, there is a waiting period that stretches from six months to a year in case of pre-existing conditions when there is a lapse of coverage for over 63 days. If one leaves their job for such diseases like diabetes, then going for an individual insurance policy would be the right choice. One can also get coverage from spouse's employment or somewhere else. This is done so that there is no waiting period with the next policy.

Non-traditional Treatments

Health insurance policy does not include alternative and complementary medicine. Alternative medicine is treatment taken instead of conventional medicine while complementary medicine is treatments as well as procedures adopted along with the conventionally used medicine. Acupuncture, acupressure, biofeedback, yoga and massage are considered as non-traditional treatments. Many health insurance plans also include chiropractic treatments as alternative medicine.

Treatment of Mental Health

There are some plans that cover treatment of mental health and drug rehabilitation. However, one has to get referral from a doctor to get these kinds of services.

Cosmetic Surgery

Cosmetic surgery generally does not get coverage under health insurance. This type of treatment is done as reconstructive operation after some injury or as a congenital defect.

Home care and Private Nursing Care Expenses

Health insurance does not include expenses incurred as a result of home care and private nursing care. This makes these expenses to add up to a considerable amount that may make the patients as well as their families bankrupt.

Other kind of Exclusions

Insurance companies do not include many drug benefits. These drug benefits fall under the cosmetic or non-traditional categories. Cosmetic purpose drugs are not included under the insurance plan. These include hair growth stimulants and clear skin and nail supplements. Similarly, drugs meant to abort pregnancy are also not included in the health insurance coverage.

Waiting Periods in Health Insurance

Health care insurance is also affected by the waiting periods. Waiting period is the time period mentioned in the health insurance policy that must pass before the start of some or all of the healthcare coverage. Three main types of waiting periods are found in health insurance. These are the employer waiting periods, periods of pre-existing condition exclusions and affiliation periods.

Employer Waiting Periods

This is the commonest waiting period that is available in an employer group plan. Here, a new employee has to wait for a certain period that is normally within three months to be eligible for availing health care services. Often, it is the employer who imposes this waiting period.

Pre-existing Condition Exclusion Period

In this type of waiting period, the individual has a condition in the last six months before the signing up of the insurance plan. The duration of this waiting period can be from 1 to 18 months.

Affiliation Period

If an HMO imposes the waiting period and not the employer, then the waiting period is known as affiliation period. This waiting period are within three months and comes with certain rules along with it.


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