Health Insurance Articles

Where To Find Exclusions In Your Health Insurance Contract

2010-06-25

It's fair to say that most people don't read their entire health insurance policy word for word. Frequently, the insurance contract is filled with confusing terms clouded by hard-to-understand wording. All too often, you might be surprised by a denial of service when you go to visit a doctor for treatment, especially if you're visiting a specialist. While you may still have room under the financial limits of your policy, your service may have exceeded the limits of another element of health insurance-the exclusion.

Exclusions and limitations are clauses that specify exactly how much and how often an insurance company will pay for certain treatments. Both exclusions and limitations need to be fully understood so you can receive the best coverage available under your policy. Carelessly scheduling too many services in too short a period may exhaust your available services covered by exclusions.

A good example of this might be with psychiatric treatment or perhaps drug rehabilitation. If you or another member of your family requires these services, they will usually be covered by a good health pan. Of course, these services will fall under the same tenets as deductibles and co-payments for any other service.

However, all your treatments may not all be covered because your insurance contract probably has an exclusion clause. That clause excludes certain services, usually based on frequency and types of treatments. You may have a limit of ten visits to a psychologist per year. It's also possible that the exclusion may be monetary. Your policy may have a five thousand dollar limit for drug and alcohol rehab. Prescriptions may also have exclusions and limitations that will restrict the frequency and quantity of refills on some medications to accepted norms.

It's also possible for the exclusion to combine treatments to reach the limit. For example, you may need ten physical therapy sessions followed by 15 occupational therapy sessions. Your insurance, however, may have an exclusion stating that you are only covered for a total of 20 visits for one injury to either a physical or occupational therapist.

Chiropractic treatment may also have exclusions. The care of a chiropractor may be combined with physical and occupational therapy. Chiropractic treatments add up fast, with twice-weekly adjustments and routine X-rays. You might reach your policy's limit for both therapy and radiology.

Exclusions aren't the end of hope. Thoughtful advice by your physician will direct you toward ways to circumvent some of these exclusions by distributing your care under different headings. You may also be able to have an exclusion waived or modified if it is very important to your particular needs. Read your policy, ask for advice, and you'll easily cross the mine field of exclusions.