17.2 Common Exclusions or Restrictions
As with every contract and for those especially that we have already addressed, health insurance policies also contain certain exclusions or restrictions.
What is the purpose of the exclusions provisions of a health insurance policy?
The exclusions clarify the causes of loss and types of losses that are not covered.
Before we look at some of the other more detailed exclusions, be aware that each of the following is normally a universal exclusion and is self-explanatory.
Exclusions
- War injuries
- Self-Inflicted injuries
- Crew members of aircraft
- Hernia (usually limited to 6 months)
- Riots
- Injuries suffered while committing a felony
- Extended overseas stays
- Injuries suffered through the use of illegal drugs or narcotics
Restrictions
Some items are not necessarily excluded, but they do contain restrictions on their benefits. The following are a few of the most common.
Maternity Benefits
Maternity benefits in individual health insurance policies may have to be added onto the policy for a higher premium. The policy may provide a lump sum benefit for childbirth or perhaps a statistical portion of the daily hospital room benefit.
Preexisting Conditions
Preexisting conditions are those ailments that existed before the policy was issued. Some people think that if they don't put it on the application, the insurer will never find out. However, the applicant owes it to the insurer and to himself to list any preexisting conditions. The insurer may opt to inflict a waiver from coverage for the particular condition, may include it and charge additional premium, or may deny the application altogether. Chances are, though, that as long as all information has been disclosed on the application appropriately, the insurer will include coverage for the condition but may invoke the preexisting conditions provision. At least the information is out in the open so that if anything related should happen, there will be no question regarding coverage.
Waiver for Impairment
Waivers for impairment are used in those gray areas where a person may have preexisting conditions, yet can still be considered insurable. These waivers exempt specific reasons for coverage but still provide protection for other health hazards. Waivers are dated and signed by an officer of the company, and in some cases by the applicant as well. These waivers can be removed if the insured's condition improves.
In Addition
An insurer issuing any type of life or health insurance policy may not deny coverage, increase premiums, or otherwise discriminate against an insured or applicant on the basis of the lawful ownership or possession of a firearm.
No individual can be required to purchase health insurance except as a condition of (1) public employment, (2) voluntary participation in a state or local benefit, (3) operating a dangerous instrumentality, (4) undertaking an occupation having a risk of occupational injury or illness, (5) an order of child support, and (6) activity between private persons.
A health insurance policy or an HMO contract (including a group, franchise, or blanket policy) under which coverage is purchased in whole or in part with any state or federal funds through an exchange created by the Federal Patient Protection and Affordable Care Act may not provide coverage for an abortion except in limited circumstances such as rape incest, or physical disorder of the pregnant woman.
