By Farooq Ahmed Farid | 24 Aug 2020

What Typical Exclusions Apply to Health Insurance?

This blog looks at some of the most typical exclusions that apply to private health insurance plans so you know what to look out for when finding the right plan for you.

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While taking out a private health insurance plan it’s important to be aware of what exclusions will apply, so you don’t get caught out with any unexpected medical expenses.

This blog looks at some of the most typical exclusions that apply to private health insurance plans so you know what to look out for when finding the right plan for you.

Your Level of Cover vs Exclusions

Insurers typically offer various levels of cover for customers to choose from. If you opt for a less comprehensive plan that does not include cover for certain medical expenses, such as dental and maternity, strictly speaking these are not an ‘exclusion’. However, as you've elected not to add these to your plan you will not be covered for these medical expenses.

For example, with our Now Health International plans you can choose a plan which covers you for In-Patient and emergency treatment only, or a more comprehensive plan that includes dental and maternity cover. You may also be able to add a range of additional options, such as cover for vaccinations and more.

Don’t forget that a domestic health insurance plan will  only cover you for the cost of treatment in your country of residence, but not for treatment when travelling abroad. Whereas an international health insurance plan will cover you for treatment both at home and abroad, depending on the geographical area of cover you select.

However for this blog we are not going to look in detail at which level of cover you should choose, but instead focus on the more common exclusions that apply as standard across most private health insurance plans.

A Note on Pandemics

Until this year, if you were looking for a private health plan you probably didn't even think about whether your insurer would cover treatment costs for a pandemic condition. However today that will likely be one of the first questions you ask!

Some domestic and international health insurance providers have a blanket exclusion on pandemics meaning you would not be covered for COVID-19 treatment. However at Now Health International there is no pandemic exclusion across our plans, so if you are diagnosed with COVID-19 the usual terms and conditions of your plan would apply.

In a post COVID-19 world, this is a good exclusion to look out for when searching for the right plan for you.

Pre-Existing and Chronic Medical Conditions

Pre-existing medical conditions are the most common and well-known health plan exclusion. In most cases you will be asked to declare any pre-existing medical conditions when applying for a plan, and these will likely be excluded, or limited, from your cover in some way.

A pre-existing condition is anything that you have undergone treatment, tests, or investigations for, that you have been diagnosed with or that has led to you being hospitalised, before purchasing your plan. It’s important to declare any pre-existing medical conditions as part of your application process; failure to do so is classed as non-disclosure and could invalidate your insurance cover.  

There are certain types of underwriting options, such as Medical History Disregarded or Continuing Personal Medical Exclusions (CPME), that might mean a pre-existing condition could be covered by your plan. However you’ll need to check with your insurance provider first and you should be aware that these types of plans are likely to come with a higher premium, as the insurer will need to factor in the risk of your pre-existing condition.

In addition to pre-existing medical conditions, some insurance plans also exclude ‘chronic conditions’. This usually refers to a medical condition that requires long term monitoring, is likely to recur or has no known cure – examples include diabetes, asthma and arthritis. If you have a chronic condition you should check if this is covered by your plan. At Now Health International, all of our WorldCare plans (excluding the Essential plan) provide cover for chronic conditions.

Cosmetic Treatment

Cosmetic treatment is another common exclusion that applies to almost all health insurance plans, including when treatment has been prescribed for conditions such as acne and alopecia. This is because such treatment may be considered a matter of personal choice.

In some exceptional cases you may be able to reclaim the costs of certain cosmetic treatments such as for reconstructive surgery after an accident, although this is not common.

Dangerous or Hazardous Sports

In the majority of cases if you are injured as a result of undertaking a dangerous or hazardous sport then your medical expenses will not be covered by your insurance plan. These could include activities such as base jumping, bungee jumping or paragliding.

If you do take part in such activities, it is best to check the details of your health plan and see whether you may be required to take out additional cover. For example you may be covered for treatment of an injury resulting from skiing on-piste, but ‘off-piste’ skiing would be excluded.

Experimental Treatments

Most health insurance plans exclude the costs for medical treatment that has not been proven effective or which is experimental. This means you are only covered for established treatments that have undergone appropriate clinical trials and assessments, and which have been sufficiently evidenced and published in medical journals.

Any prescribed drugs will also usually need to be licensed for use by the relevant health authorities, such as the European Medicines Agency for those living in Europe. However it is highly unlikely your doctor will recommend an experimental treatment, except in extremely rare cases, so you don’t need to worry too much about this exclusion.

Medical Charges not Deemed ‘Reasonable and Customary’

Many plans will exclude cover for treatment charges deemed outside of the insurer’s ‘reasonable and customary’ range. A charge is considered reasonable and customary if it aligns with the average costs for that service within your geographical area. This means that if your doctor charges above this level then you may have to pay the difference.

If you are unsure about whether your treatment cost meets this criteria you can check with your insurance provider. Another way to prevent being caught out is by seeking treatment at a medical provider within your insurer’s network, or by seeking treatment pre-authorisation in advance.

Routine Health Screenings

Your plan will likely exclude cover for routine health screenings or wellness check-ups; this refers to a routine screening to rule out a condition that you do not currently have symptoms for. For example this could include your annual cervical smear test.

However some international health insurance plans, including our plans, do give you the option to add a wellness benefit for an additional cost, which can give you cover for certain health check-ups and vaccinations.

Second Medical Opinions

If you are unhappy with your doctor’s advice and want to seek a second opinion from another specialist, these expenses will be excluded by most private health insurance plans.

However, at Now Health International our flagship WorldCare plans do come with a complimentary second medical opinion service as part of the added value services we offer. Please note we only cover the costs of the second medical opinion if it has been expressly authorised by us. You can find out more about the benefits of a second medical opinion in our blog here.

Travel and Accommodation Costs

Travel and accommodation costs incurred during trips to undergo medical treatment are another common exclusion across most health insurance plans. This means your health insurance would not usually cover the costs of your taxi ride to the doctor’s surgery.

However it’s worth noting that unlike domestic health insurance plans, an international health insurance plan will cover you for emergency medical evacuations and repatriation. For example if you need to be taken by air ambulance to the nearest specialist hospital, which may even be in another country, this travel expense would be covered. You can read about one such case involving a Now Health International member on our ‘Customer Stories’ page here.

Know the Exclusions on Your Health Plan!

While all private health plans have exclusions these won't be the same with every insurer. It’s important to take the time to understand what exclusions will apply before purchasing a plan to ensure it is right for you.

If you want to know more about what is and isn’t excluded within our Now Health International plans, then you can view our member handbooks and brochures for more information here. If you are still unclear about anything, you can contact our team who will be happy to help.

By Farooq Ahmed Farid

Farooq is a qualified actuary, a risk & underwriting management professional, strategist and data scientist. During his career, Farooq has been instrumental in helping to develop international best practices across underwriting, technical pricing, actuarial, analytics, product development, risk management, reinsurance, and business intelligence in order to implement successful strategic business plans.

See Farooq Ahmed Farid's profile