What is Included And Excluded in Health Insurance Plans

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Reader’s Question:

I understand very little about health insurance policies, and I constantly feel in the dark. I do not even have a clear idea of what might not be included, and this worries me. I’ve just always thought that health care insurance policies would save me from exorbitant medical expenses! Can you explain some of the limitations of a health insurance policy? I live in Louisiana.

Joy

New Orleans, LA

If you think that your health care plan includes every medical cost you might have in the future, you’re up for a surprise. Mostly, a very good health insurance plan means that you will only need to pay for a minimal amount, but certainly there are limitations to what is covered. Here are some exclusions to your health care policy.

First of these are pre-existing conditions. Many health insurance companies are reluctant to shoulder the cost of those medical conditions that you already had before you bought the health insurance policy. Insurers generally have an exclusion period of about 6 months; The state of Louisiana allows this period to be as long as one year. This means you cannot get coverage for pre-existing conditions within the first 6 or 12 months, depending on your contract.

Another is drug abuse. This exclusion assumes that you have inflicted the problem upon yourself. So, in the same way, attempts at committing suicide are excluded. So is alcoholism.

Mental illness–especially if it has already manifested before the start of your contract– will not be covered, as well. So, your psychiatric care will not be paid for by the health insurance company. The same goes for any treatment for learning and behavioral problems.

Cosmetic surgery is not vital to life or living, so looking more beautiful is something you will have to spend for on your own. Most medical procedures considered to be preventive are part of the exclusions, too. So are dental and eye care.

Of course, the best advice I could give is for you to make sure that you read your contract with any insurer very carefully and ask your health insurance company the questions that boggle you.

Tags: Health Care, health insurance, insurance

What affects the appeals process for a health insurance claim denial?

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Reader question:

I need to file a health insurance claim appeal because my claim was denied, and I would like to know what are the factors that affect the process of the appeal?

Lauren

Great question.

If a health insurance company wants to be accredited with the National Committee for Quality Assurance, then they have to provide the right to get an external appeal reviewed by a board of medical professionals in their health plans. It’s possible for this right not to be included in a medical health insurance plan, but the idea there is that it only isn’t when the employer pays for all of the health insurance costs. There are, in addition, a few laws from the federal and state governments that affect the health insurance claim appeal process.

• Federal government laws
  • The President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry has created a process by which the appeals must go. If the medical health insurance plan is a federal one, then it has to go by the regulations instituted by the Commission.
  • In the same vein are medical health insurance plans that contract with Medicare. If a medical health insurance plan does this, then it comes in the contract that they have to go by the laws of the Commission as well if they want to continue working with Medicare.
• State Laws
  • There are laws that regulate who can be on the board that is reviewing the appeal of your health insurance claim. It is required that they at least be a medical health professional, and in many states they have to have a medical license in order to be on the board.
  • Most states also have laws instated that say that your own doctor can go through the appeal process for you if they believe it is right to do so. This is why you usually want to get help from your doctor to go through the appeal process.
  • Some health insurance plan will dole out awards or punishments based on whether or not a doctor recommends medical procedures or treatments that the plan does not want to pay for. Many states have laws that protect a doctor’s ability to do so and be protected.
  • Many states even have groups of patients going through a health insurance claim appeal that can meet together, sponsored by the state, and help each other with the process.

Cheers,

Fashun Guadarrama.