Limitations and Exclusions on Health Plans

Whether you’re shopping for a qualified health plan, a short-term medical plan, accident plan, dental plan, etc., limitations and exclusions may apply. It’s important to understand the limitations with the plan you’re shopping for before purchasing it. Typically, the limitations and exclusions of health plans are standard across all insurance carriers about 85% of the time. For instance, carriers won’t cover medical expenses if the injury happened while committing a felony. Similarly, carriers won’t cover injuries from a car accident if the person was driving intoxicated.

However, though most limitation/exclusion clauses on health plans are the same, some are a little different. Therefore, it’s prudent to know if the plan you’re about to purchase has limitations that veer from the norm. Ultimately, the limitations and exclusions can supersede the benefits of the plan.

To illustrate, let’s say you’re shopping for an accident plan, and you’ve narrowed down your options to Company ABC and Company XYZ. In the limitations and exclusions clause, option ABC does not cover sports-related injuries. Additionally, they coordinate benefits, meaning if your out-of-pocket is zero then they pay zero. On the other hand, XYZ does not have any limitations regarding sports nor does it coordinate benefits. This means that XYZ will still pay out benefits even after you’ve met your maximum out-of-pocket. So if you have children who play sports, then Company XYZ is the better option; unlike ABC, option XYZ will pay the claim for a sports injury. This is just one example of why it’s important to read the limitations and exclusions of a health plan. In order for insurance to offer the peace of mind it’s intended to give, then you need to know what a health policy does and does not cover.

To ensure your plan’s limitations and exclusions don’t conflict with your needs, consult an agent; they’ll make sure your plan is a right fit. Moreover, they can explain if certain limitations/exclusions are common across the board or if they’re particular to an insurance company.

Limitations and Exclusions

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This Article Was Updated On: 04/24/2024.

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