Nov 092011

You and I both tend to think that if we have health insurance then our insurance company should pay for the health services we receive.  Unfortunately, we are wrong.  Each insurance plan will have limits called Exclusions.

Types of Coverage Exclusions

Companies can limit the types of health treatment that they cover. For example an HMO plan does not cover out of network providers, so if you saw an out of network provider your claim would probably be denied payment.


Treatment Exclusions

These types of exclusions cover a wide range of topics from level of care to following your plan requirements.  For example, some health plans will not cover residential levels of care as treatment.

Of course there is also the all-covering: medical necessity.  If the doctors that work for your insurance company feel that you could have been treated differently then they may deny your claims payment.  However, remember you have appeal rights.

Another primary exclusion under this type is if you or your provider did not follow your insurance plan requirements.  For example if you were required to get an authorization before services but you didn’t, then the claim may be denied.

Experimental and Investigational treatments (as determined by your insurance company) will not be covered.  This is very common and often applied to ABA therapy for Autism.  While the laws surrounding Autism treatment are changing, there are still some loopholes that insurance companies are using to deny this and classifying it as experimental is one of them.

Prescription, Vision, and Dental Exclusions

Essentially all parts of your insurance coverage may have exclusions.  Sometimes an insurance plan will refuse to cover a specific medication because they feel there are others available or they deem it experimental.

Many vision plans exclude voluntary treatments, like lasik surgery.

Dental plans will only cover certain amounts of treatments before excluding them as not medically necessary.

The point here is to know what is excluded from your plan.  If possible, you should always consult each section of your Plan Documents (certificate of coverage, member handbook, summary plan descriptions, plan document, etc) for their own exclusions before receiving treatment.



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