OK, so, I wanted to write a page about the exclusions and limitations in a health insurance policy.
So, in a totally new, never-before-done article I wanted to illustrate some of these exclusions and discuss them line by line. I chose Cigna because it was the first one that I picked randomly, and I am certainly not picking on Cigna as everyone else’s plans are virtually identical, and literally filled with the same exclusions and limitations.
It is more an attack on the health insurance industry and I am not vindictive at all towards Cigna.
In any event, let’s look at some of these plan exclusions and discuss them. Feel free to email us, give us some suggestions and share your experiences with these individual or even group health insurance exclusions.
Individual and Family Plans
EXCLUSIONS AND LIMITATIONS
Any amounts in excess of maximum amounts of Covered Expenses stated in this Policy.
— Many policies have benefit maximums on certain covered conditions, though in most states this mainly applies to psychological conditions and issues.
Services not specifically listed in this Policy as Covered Services.
— Obviously, health insurance companies will not cover breast implants, don’t even ask us about this, it is completely ridiculous. In the event of breast cancer, however, surgical reconstruction of course is covered.
Services or supplies that are not Medically Necessary.
— Real simply, we are not going to cover that mole removal for cosmetic reasons or pay for you to have an unnecessary surgery cosmetic or otherwise.
Services or supplies that CIGNA considers to be for Experimental Procedures or Investigative Procedures.
— This is a particularly gray area, because if you have seen the movie Saw VI then you must know that sometimes these surgeries might increase the chance of living longer or a higher quality of life, but the costs are prohibitive and the health insurance companies could go broke trying to cover every single one of these procedures.
In the end though, everyone deserves to be able to fight for their lives, and to deny coverage for a procedure that is labeled experimental can be very unethical because in essence the insurance company could actually hasten your demise. How these people can sleep at night, and I mean the people that make these decisions is beyond me, and I would sooner be homeless and broke rather than accept this job.
Services received before the Effective Date of coverage.
— This is for you jokers that sign up for a health insurance policy right when you realize something might be wrong. This would be the other side of the coin, when a perfectly middle class person decides to forgo health insurance only to try to sneak in when he needs it. This person, is just as bad as the people that decline experimental treatments, because they contribute to our system being broken firstly, and secondly raise premiums for everyone else.
Services received after coverage ends.
—Duhh. If your policy lapses for any reason, you are on your own.
Services for which You have no legal obligation to pay or for which no charge would be made if You did not have health plan or insurance coverage.
—Prevents scams for services not received or performed from being billed to health insurance companies.
Any condition for which benefits are paid, recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law or occupational disease law, even if the Insured Person does not claim those benefits.
—-A victim of a litigious action who collects a settlement for medical costs cannot also collect from the health insurance company. Just like you can’t have two health insurance policies at the same time.
Conditions caused by: (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an Insured Person participating in the military service of any country; (d) an Insured Person participating in an insurrection, rebellion, or riot.
—This is a fair exclusion, that says if you fight in Iraq and get hurt, they are not responsible. But of course our military is covered under their own VA plans.
Any services provided by a local, state or federal government agency, except (a) when payment under this Policy is expressly required by federal or state law.
—Again prevents a company from paying claims that are being payed by another party, in this case the government.
If the Insured Person is eligible for Medicare part A or B CIGNA will provide claim payment according to this Policy minus any amount paid by Medicare, not to exceed the amount CIGNA would have paid if it were the sole insurance carrier.
–Same thing as above, but this prevents duplicate payments from Medicaid or Medicare.
Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation.
—Already covered cannot be paid out twice. Obviously, the insurance companies are serious about this!
Professional services received or supplies purchased from the Insured Person, a person who lives in the Insured Person’s home or who is related to the Insured Person by blood, marriage or adoption.
—Unless your policy covers your family as a medical provider they cannot be compensated for medical care or medical supplies.
—They are not covering any kind of home-bound nursing custodial care.
Inpatient or outpatient services of a private duty nurse.
—The insurance companies feel that this nursing expense can be covered under another policy such as Disability or SSI.
Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
—-OK, we get it! No nurses. I guess you will have to do your own sponge bath, you perv!
Assistance in activities of daily living, including but not limited to: bathing, eating, dressing, or other Custodial Care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care.
—Again, these activities are covered under other types of policies such as home health care or long term care coverage.
Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
—A very fair limitation. Don’t check into the hospital for a procedure that is or can be performed outpatient. Further, keep in mind that most health insurance companies will encourage you to go to these types of outpatient facilities to limit your bills and theirs.
Treatment of Mental, Emotional or Functional Nervous Disorders or psychological testing except as specifically provided in this Policy. However, medical conditions that are caused by behavior of the Insured Person and that may be associated with these mental conditions are not subject to these limitations.
—Psychological conditions are very expensive and in most states where they don’t mandate this type of coverage the insurance companies will skimp as much as possible on this kind of coverage. Group health insurance is much better for this type of health coverage.
Again, individual health insurance is not great for mental health, but some Affordable Care Act plans cover such services to some degree. If you have mental health problems (depending on your home state of course) form a corporation and get a group health insurance policy. Check your local individual options as well.
Smoking cessation programs.
—This is nuts, but because most smokers quit smoking more times than they smoke this is not yet covered. Should smoking cessation programs increase their quitting percentages, I would not be surprised to see this covered. But for now, remember the patch is cheaper than cigarettes now.
Treatment of substance abuse.
–A quick substance abuse program can cost $20,0o0 for a month. Profit lines would be harmed and shareholders would get angry if substance abuse were covered. Interestingly, it is now required for individual policies under Obamacare. So just like mental health coverage, stick to group health insurance if you abuse drugs – or find the right ACA health plan.
Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this Policy.
–Shockingly, health insurance plans don’t cover dental health insurance. Get a separate policy for dental. But remember individual dental plans are complete garbage. They make group dental plans look comprehensive in comparison. They are mostly discount plans, these individual dental plans.
Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction.
–TMJ, which my mother had, is not covered, this is a painful and annoying condition for which there is no cure, and obviously falls under dental insurance as does braces and other dental procedures. Get a dental policy, cheapskate!
Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
–Interestingly enough dental implants can be covered (at around $3,000 per tooth) if there is an accident where the tooth is broken due to an accident rather than decay.
—I guess you won’t be getting that bionic ear after all. Hearing aids are super expensive but like glasses they are covered by some plans but only discounts are provided.
Routine hearing tests except as provided under Well Baby and Well Child Care and Newborn Hearing Benefits.
—I guess health insurance companies don’t care if your newborn is deaf. Great job Cigna!
Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Policy.
—Again just like dental, there is no vision coverage. There is no such thing as vision insurance by the way, the only thing you can get is a discount plan.
An eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), astigmatism and/or farsightedness (presbyopia).
— Again no vision coverage.
Outpatient speech therapy, expect as specifically provided in this Policy.
—So no sttttuttering coverage. I guess this is fair, but again stuttering (I apologize for the joke, but this article would be pretty boring otherwise) or speech therapy is very expensive.
Cosmetic surgery or other services for beautification, to improve or alter appearance or self esteem or to treat psychological or psychosocial complaints regarding one’s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty; and blepharoplasty. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for Medically Necessary Reconstructive Surgery performed to restore symmetry incident to a mastectomy.
—To be fair, these are not benign medical conditions, and in fact gyno (or bitch tits as they are called in the steroid world) is in many cases caused by steroid usage. Moral hazard, as it’s called.
Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books.
—Well explained Cigna. I applaud the veracity of this exclusion but severely frown on the implications. Way to help the blind. If you are not going to cover these therapies I hope that you give very generously to the blind charities.
Nonmedical counseling or ancillary services, including but not limited to: education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning disabilities and developmental delays.
—I applaud you again, Cigna, for explaining without a shred of remorse that you will not help anyone if you can help it. Of course someone must have abused this system at some point to get such strong language, but I find it reprehensible. Shut up Cigna, and have a heart. There is really no reason for this, and I am writing this commentary as I read this and am utterly disappointed by this clause.
Services for redundant skin surgery, removal of skin tags, acupressure, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, pryotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications.
—Some of these therapies are very new age and have not been studied enough to know if the therapies yield any significant results. I guess understandably Cigna has chosen to exclude these therapies. Dance therapy? Someone had to have submitted a claim for this for it to be prohibited. I wonder what condition can be improved with a little boogie?
Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
—Fair enough, if you want to remove your genitalia (or add some), it is on your dime.
Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an Accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies.
—Some plans will cover Viagra or similar medication, but these medicines (I use that term loosely) are often abused and are totally not necessary but do improve the quality of life. I am sympathetic to both the insured and the insurance companies here, and a good indicator of the fairness of an exclusion is to imagine a single payer health insurance system. Would the government cover this kind of therapy?
All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, except as specifically stated in this Plan.
–If you want a vasectomy, I guess you will need to save up for it. Obamacare now requires health plans to cover most birth control methods, but IVF still isn’t covered.
All contraceptive services and supplies including but not limited to all consultations, examinations, evaluations, medications, medical, laboratory, devices, Prescription Drugs, or surgical procedures.
—Some plans cover generic or even name brand contraception, but this is far from a medical necessity, and I have often been asked if an insurance company will cover this. I often respond by reminding people that health insurance is for emergency medical coverage, that was the initial intention, all of this other stuff is counter to the purpose. This type of thing is one of the main reasons for the failure of our medical system.
All non-prescription Drugs, devices and/or supplies that are available over the counter or without a prescription.
—Let’s remember prescription coverage is named for the fact that it covers prescriptions. Next…
Cryopreservation of sperm or eggs.
—Buy your own freezer, Ted Williams.
Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
—This might fall under the category of superfluous, but the pain that comes with some of these conditions can be unimaginable. Still, I guess it would fall under the category of kitchen sink.
Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the Insured Person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction.
–Jenny Craig is not a prescription, and gastric bypass is elective. I get this question a lot, but it is honestly ridiculous. I do believe that overweight people are not always to blame for their condition and that genetics can play a huge role, but this in most cases is an illness that is similar to drug abuse, but it is an illness and falls into a very gray area.
Routine physical exams or tests, except as specifically stated in this Policy.
—You get one physical per year with all companies completely covered, any other testing will usually be applied toward your deductible, and if the testing is not medically advised the insurance company will have the option of not covering it. Get a referral just to be safe.
Charges by a provider for telephone or email consultations.
—Some companies (I guess not Cigna) have online doctor consultations for small copays. This is an excellent idea as it saves money and time for everyone. Get an e-doctor Cigna, you can afford it!
Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs etc.).
—I guess Cigna wants you to get your own air conditioning.
Educational services except for Diabetes Self-Management Training Program, and as specifically provided or arranged by CIGNA.
—Diabetes is one of the most expensive chronic conditions. Most health insurance companies would sooner insure a dead person than a diabetic. Cigna obviously is not a strong believer in preventative care.
Nutritional counseling or food supplements, except as stated in this Policy.
—I guess Cigna won’t cover my Creatine or MetRx meal replacements. But really, did you really think that they should?
Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this Policy. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings.
—Didn’t we already do this one?
Physical, and/or Occupational Therapy/Medicine except when provided during an inpatient Hospital confinement or as specifically provided under the benefits for Physical and/or Occupational Therapy/Medicine.
—Physical therapy is often excluded in most policies wherever possible, that is for good reason though. Many people treat these therapy sessions as a personal trainer and end up billing insurance companies unfairly and often.
Self-administered Injectable Drugs, except as stated in the Prescription Drug Benefits section of this Policy.
—Cigna wants your doctor or nurse to do your injections for your chronic condition. The why part logic escapes me.
Syringes, except as stated in the Policy.
—Part of diabetes and chronic condition coverage, which could easily bankrupt a company.
All Foreign Country Provider charges are excluded under this Policy except as specifically stated under Treatment received from Foreign Country Providers in the Benefits section of this Policy.
—Very important limitation here, foreign travel is often not covered by most companies, if you are traveling make sure to look at your policy and see if it has this exclusion if it does, make sure that you get a travel health insurance policy.
Growth Hormone Treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the Insured Person’s condition.
—GH is actually an unproven therapy, many physicians are uncertain if the benefits outweigh the risks due to the fact that it can increase the size and presence of tumors. This is more than fair and I applaud the verbiage here.
Routine foot care including the pairing and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary.
—Well said Cigna, podiatry is not covered for elective surgery. Fair enough, period.
Charges for which We are unable to determine Our liability because the Insured Person failed, within 60 days, or as soon as reasonably possible to: (a) authorize Us to receive all the medical records and information We requested; or (b) provide Us with information We requested regarding the circumstances of the claim or other insurance coverage.
—If you have a claim make sure to send Cigna all the documentation as soon as you can and to be sure that you file your claim promptly.
Charges for the services of a standby Physician.
—This is a nutty clause. I don’t agree with this at all. There are many easy to imagine circumstances where this could cost a person valuable time and quality of life, even life itself, which should never be controlled by the whims of an insurance company. You dig?
Charges for animal to human organ transplants.
—Did you really ask Cigna to transplant a monkey penis?
Charges for Normal Pregnancy or Maternity Care, including normal delivery, elective abortions or elective/non-emergency cesarean sections except as specifically stated under ‘Complications of Pregnancy’ in the ‘Comprehensive Benefits’ section of this Policy.
—This is a slippery slope and I tend to agree even though I am going to suffer personally and financially from this clause when my wife and I decide to have children.
Claims received by CIGNA after 15 months from the date service was rendered, except in the event of a legal incapacity.
—File your claims quickly.