Understanding Health Plan Limitations and Exclusions

No health insurance plan covers everything.

Every health plan includes a section called the limitations and exclusions. This is a list of medical services and equipment your health plan won’t pay for. To save yourself from any unpleasant surprises when you file an insurance claim, it’s a good idea to read this section carefully before you decide to apply for a plan.

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The challenge of reading this section is that it’s written like a legal document. A plan’s limitations and exclusions section is usually packed with the kind of words lawyers use — and, yes, it’s usually in fine print. But it’s worth taking the time to read through it all the way.

Common health plan exclusions include:

  • Glasses or contact lenses

  • Physical therapy

  • Rehabilitation for substance abuse

  • Fertility treatment

  • Cosmetic surgery

Remember that these are just examples. The specific medical services and equipment excluded from your plan may be different.

So… My Health Plan Covers Everything Else?

Does that mean that all medical services not listed in the limitations and exclusions will be covered? Not necessarily.

If you have pre-existing medical conditions when you apply for coverage, your plan may come with additional exclusions. These exclusions will be outlined in a separate document, which is attached to the plan description you receive after you’ve enrolled. This document is called a rider.

Usually, the extra limitations in a rider are only in effect for a pre-defined waiting period. This waiting period can be as long as a year.

Why do companies include riders? The idea behind having health insurance is to protect yourself against risk — not to pay someone’s medical bills after they get sick or have an accident. Including a rider limiting coverage for pre-existing conditions prevents people from joining a health plan and filing an expensive claim the very next day.

If you do have a pre-existing condition, it’s worth remembering that every company uses a different set of rules when they decide which applications to accept, and which ones get riders attached to them. That’s why getting advice from a professional agent is a smart option to help you choose a plan. Use our free service to connect with multiple agents without any cost or obligation.

If you want to explore plans online, get an instant health insurance quote. You’ll be able to view plans online and compare benefits. You can even download plan brochures, and check out the limitations and exclusions before you decide which plan is right for you.