Limitations, Exclusions & Riders

Understandably, it would be impossible to find a health insurance policy that covers every illness or medical condition without limits or exclusions. Most policies specify certain types of injuries, illnesses, or procedures for which they provide a lower level of coverage. Furthermore, certain illnesses, injuries, and procedures may not be covered at all. Limitations are conditions or procedures covered under a policy but at a benefit level lower than the norm. Exclusions, on the other hand, are conditions or procedures that are completely omitted from coverage. Your health insurance policy should list all limitations and exclusions.  Therefore reading and understanding one's health policy is certainly an important thing to do.

What are some common limitations and exclusions?
Although the specifics of limitations and exclusions do vary from policy to policy, the following is a list of common limitations and exclusions a standard policy might include:

• Pre-existing conditions: A pre-existing condition is an illness or injury that began or occurred before you obtained coverage under a policy. Pre-existing conditions are often excluded from coverage, or may be covered after a specified waiting period.
• Nonduplication of payments/coordination of benefits: In order to prevent double coverage, many policies specify that benefits will not be paid for amounts that are reimbursed by other insurance companies. This provision limits the total payment of benefits to 100% of covered expenses.
• Alcohol and/or drug abuse treatment
• Care covered by the Veterans Administration or workers' compensation
• Cosmetic surgery: Cosmetic surgery required as the result of an accidental injury or congenital defect is generally not excluded.
• Dental expense: Some policies may cover reconstructive dental treatment resulting from accidental injury.
• Experimental procedures
• Hernia
• Infertility treatment
• Injury incurred while committing a felony
• Injury, illness, or death that occurs while under the influence of intoxicants or narcotics
• Military duty: This provision usually suspends the policy while the insured is serving in the military.
• Noncommercial airline travel
• Organ transplants
• Self-inflicted injuries
• STDs
• Vision correction
• War or acts of war that result in injury or death

What is a rider?
Insurance policies are usually written in a standard form, most of which is dictated by state insurance law. If you need additional coverage or if there are changes to the standard document, these changes can be made by way of a rider. The information to be conveyed in the rider is typed up on a separate piece of paper, which is attached to the standard policy. An endorsement can accomplish the same goal; the only difference is that an endorsement is actually incorporated into the body of the existing policy. Some common health insurance riders are as follows.

Multiple indemnity
In some health insurance policies, accidental death or dismemberment benefits may be doubled or tripled depending on the cause of death or specific type of dismemberment. This multiple indemnity may be included in the policy by way of a rider.

Waiver of premium
Some policies may allow you to skip premiums during periods of extended hospitalization.

Exclusion
Also called an "Impairment rider," this rider is used to specify a medical condition that might normally be covered but is not covered because it is a pre-existing condition. Although the particular condition is not covered, use of this rider allows the applicant to obtain insurance for other healthcare needs when this condition might otherwise make the person uninsurable.

Additional coverage
If the insurer agrees to provide coverage that is not included in the standard insurance contract, this coverage might be described in a rider.

Please Note: The information contained in this Web site is provided solely as a source of general information and resource. It is a not a statement of contract and coverage may not apply in all areas or circumstances. For a complete description of coverages, always read the insurance policy, including all endorsements.