What You Don't Know Can Hurt You

Regardless of the kind of insurance you select, there are certain important contract provisions to watch out for.

Exclusions
As you will recall from some of our earlier discussions, exclusions in an insurance policy remove areas from coverage that would otherwise come under the protection of the insurance umbrella. Understanding the exclusions in your policy is vital if you are to truly understand your rights under the policy.
Here are some typical exclusions found in health insurance policies.
Preexisting conditions. Preexisting condition exclusions are the bane of the health insurance consumer. They can be so broad that they make a joke of health insurance "coverage."

A preexisting condition is often defined as "the existence of symptoms that would cause an ordinary prudent person to seek diagnosis, care, or treatment within a five-year period, or a con­dition for which a physician either recommended or rendered care." That leaves a pretty wide latitude, as an angry health insurance consumer living in Florida discovered when she searched for health insurance. She writes:

My search for health insurance was due to the fact my employer decided to discontinue the group plan under which I had been covered. The insurance premium had been increased drastically at regular intervals until the premium for three adults and two teenagers had reached nearly $50,000 per year.

She went on to relate how she applied for insurance. After several months she was told that a policy would be issued but that there would be three areas of exclusion, one for her left hip, one for her back, and one for her female organs. She continues:

I was stunned, to say the least and asked [the underwriter] why. He told me that since 1 had been in an auto accident in 1983 and had received treatment for a back sprain, they could not cover my back; that since I had inflammation in my left hip, even though I had not seen a doctor about the conditionfor over a year, they could not cover my hip. And since they could not locate the gynecologist who had treated me for what I listed as minor female irregularities, they would not cover my female organs. I was told that these exclusions would apply for two years and then they would review my case and a decision would be made as to whether to remove the exclusions.

Thus, under today's privatized system of health insurance, you don't even have to have a chronic illness such as diabetes or have had a heart attack or a major injury to be left out in the cold by a preexisting condition exclusion. So, be sure to check very carefully the preexisting clause of any new health insurance you are thinking of purchasing. You may find that you are paying full premiums for only a shell of a policy.

Substance abuse. Many policies exclude coverage for illnesses or injuries that arise out of the abuse of narcotics or other con­trolled substances not prescribed by a physician.

Attempted suicide. If things are so bad that you are contem­plating ending it all, be aware that any treatment you receive because of the effort will probably be on your own dime.

Mental illness. Some policies exclude benefits for mental or emo­tional illness that does not have an organic (bodily) cause. Others provide specifically defined and limited benefits for such things as psychotherapy. Be sure you understand your rights under your policy if you feel the need to consult a psychiatrist, psychologist, or other mental-health professional.

Workers compensation claims. If the injury or illness is subject to workers compensation medical benefits, the private or group policy will generally exclude itself from paying the medical bills.

Cosmetic surgery. If you don't like your looks and you seek plastic surgery to fix what you find offensive about your body, don't expect your health insurance to pay the bill. However, if the cosmetic surgery is required due to injury (or birth defect in a child born under the protection of the health policy), the cost will be covered.

Pregnancy. Many insurance policies do not cover normal preg­nancy. Often they will also not pay for an elective cesarean section. Some even exclude miscarriages from coverage, and very few will pay for an abortion. Thus, if you are pregnant or planning to be, be sure to check your policy to see what prenatal and obstetric delivery services are covered by your health insurance plan.

Eyeglasses and dental work. These services are not covered. However, dental insurance can usually be purchased as an add­on to the policy.

Treatment paid for by the government. If a government benefit will pay the bill, your health insurance company will try not to.

Prescription drugs. Unfortunately, many policies don't pay for the cost of medication. And with the cost of drugs these days, that lapse can prove expensive and potentially dangerous to your health if you can't afford to pay for necessary medicine.

Preventive care. Many traditional health insurance policies will not pay for things such as routine physicals or medical tests where no symptoms are present. Apparently these companies have never heard that an ounce of prevention is worth a pound of cure.

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