All individual health insurance policies contains clauses on preexisting conditions. Preexisting conditions coverage limitations in group policies and managed care plans are regulated by federal law. (See 42 USC Sec. 300gg(a).) Under these laws, a preexisting condition exclusion is valid only if it relates to conditions for which the insured received care or care was recommended within six months before the enrollment dates.

A preexisting conditions exclusion is valid for no more than twelve months, reduced by whatever period the insured was covered for that condition under a previous policy or managed care plan. The effect of this latter provision is often to completely negate the preexisting condition exclusion. For example, an insured covered an employer-sponsored health plan (Plan A) who changes jobs and becomes covered under the new employer’s health plan (Plan B), with no gap in coverage between Plan A and Plan B, is not considered to have any preexisting conditions that would be excluded from Plan B’s coverage.

 

Workers Compensation Exclusion

Most health insurance policies and managed care plans exclude coverage for any illness or injury covered by workers compensation or occupational disability laws. Such exclusions are uniformly enforced, even if the insured did not seek or receive workers compensation benefits. The intent is to avoid multiple recoveries.

 

Experimental or Investigative Exclusion

Many health insurance policies and managed care plans exclude coverage for treatments that are not recognized as accepted medical practice or that have not received governmental (e.g., FDA) approval. Often, policies and managed care plans put the determination whether a given treatment is considered experimental or investigative in the sole discretion of the plan’s medical director. This is an exclusion that in many ways is a variant of the medical necessity requirement discussed previously. Obviously this exclusion has been the source of contentious litigation and disputes. Most of the time the disputes are handled by an independent arbitrator.

 

A Partial List of Medical Insurance Exclusions

  • Pre-exіstіng cоndіtionѕ aѕ dеfіnеd by yоur рolіcу аnd diсtаted by stаte law.
  • Hеrnіа however the grоwing trend іs tо covеr the cоndition.
  • War аnd/or aсts оf wаre thаt rеsult іn іnјurу or deаth
  • Mіlitаrу dutу
  • Nоn-cоmmercіal air travel
  • Inјurу whіlе сommіttіng a felonу
  • Injury, іllneѕѕ оr dеath іnсurred while under the іnfluenсe оf аlсohоl or narcоtics
  • Cоsmеtіс ѕurgеrу unlеѕs fоr ѕurgеry requіrеd aѕ a rеѕult of an асcidеntаl іnјurу оr a cоngenital defесt
  • Dеntаl еxpenѕe, unless rеsultіng from ассіdental іnјurу
  • Vіѕіon cоrrесtion such аs еуe exаmѕ, eуeglаssеs аnd cоntасt lеnseѕ
  • Cаrе рrovіded by gоvеrnmеntаl or by wоrkеrs сompenѕаtіon
  • Sexuаlly trаnѕmitted dіѕеаѕes
  • Exреrіmental рroсedures
  • Organ trаnsрlаnt
  • Infеrtility treatment and sеrvісеѕ
  • Alсohоl аnd drug аbuѕe trеаtmеnt

 

Sample Health Plan List of Limitations & Exclusions

This particular list corresponds with a Humana One copay plan in Texas, which can be viewed in the process of filling out a quote. In order to see what your future health plan has in store (or won’t cover) for you, read to the end of the schedule of benefits – the final pages should always disclose what the insurer will not cover with that specific plan.