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  • Health procedures insurance companies won’t cover
  • January 16, 2014
  • declined by health insurance

    By Regina Waldroup

    As health care costs continue to climb, an increasing number of companies are passing more costs onto their employees. So even if you have a job that provides health insurance, you need to be a savvy consumer when assessing and selecting health insurance.

    Just because you’re insured, doesn’t mean that every procedure and service you might need is covered. Each plan is different, and while most plans cover basic health care services such as regular checkups, there are some services or exclusions that are generally declined by insurance companies. And when that happens, you’ll be responsible for footing the bill.

    The best way to learn what your insurance will and will not pay for: Review your policy or visit your insurer’s website for a thorough description of your rights and responsibilities. You can also contact the human resources department of your employer.

    Here’s a look at some services and procedures that are generally not covered by insurance companies:

    1. Cosmetic Surgery

    Cosmetic surgery for beauty purposes is considered an elective procedure and generally not covered by insurance companies. Liposuction, tummy tucks, breast enlargement, nose jobs, face-lifts and some dermatological procedures are considered elective.

    “Cosmetic surgery in general is not medically necessary,” says Dave Grant, assistant deputy director for health insurance products, for the Illinois Department of Insurance. “It’s not a type of coverage that could save a person’s life.”

    There are some exceptions, however. If you have a physical deformity, such as a cleft pallet, and the procedure is done for reconstructive purposes, such as after a mastectomy or because of illness or injury, health insurance usually will cover the costs.

    In some cases, breast reduction surgery is also covered by insurance if it helps alleviate related health problems, according to the American Society of Plastic Surgeons. The group’s website also says that eyelid surgery, which is nearly always cosmetic and not covered, generally is covered if the patient needs it to improve vision. In that case, it may be considered reconstructive.

    2. Lasik Eye Surgery

    Generally, this vision corrective surgery is not covered by insurance plans, but some consumers may purchase separate vision coverage that may pay for this procedure.

    3. Infertility Treatments

    Infertility treatments are typically not covered by insurance companies. But some employers offer this in their benefits plan. Under new health care reform laws, some states, such as Illinois, mandate group health insurance and HMO policies that cover more than 25 full-time employees. And often these policies must provide coverage for the diagnosis and treatment of infertility, but not necessarily the subsequent treatment.

    “Illinois was one of the first to mandate the coverage,” says Mary Peterson, acting supervisor of the life, accident and health unit for the Illinois Department of Insurance. “We are still one of the more generous states… as there’s no dollar maximum limit for the treatments.”

    4. New Technology

    “New technology that has not yet been proven to work is generally not covered by insurance companies because it could do more harm than good,” Peterson says. “Although, Illinois does have a new law on the books that says if your doctor says this is your last and best chance at survival, you may be able to get coverage for an experimental procedure. It would be considered as an allowable exclusion.”

    Insurance also rarely pays for clinical trials, where drugs are being studied or are in development or have not yet been approved by the U.S. Food and Drug Administration. Usually, whoever performs the clinical trial will provide medication to those who take part in testing of a new drug. The National Institutes of Health maintains a public database of clinical trials at

    5. Alternative Medicine

    While alternative medicine, such as chiropractic services, massage and acupuncture, are generally covered by insurance plans, it’s not universally true for all plans. In addition, companies may offer discounts for yoga and meditation, but they are not universally covered in all plans.
    According to the website for the National Center for Complimentary and Alternative Medicine, some employers also allow workers to purchase alternative medicine riders to their standard health insurance plans.

    6. Investigative Procedures

    Generally referred to as elective procedures, investigative procedures are typically not covered by insurance companies because they are not deemed medically necessary by doctors and insurance providers.

    7. Psychological Testing

    Psychological testing for education purposes is generally not covered. It’s not considered a treatment for diseases and it’s also typically done for children at schools.

    8. Oral Contraceptives

    Often called the “pill” prescription contraceptives were not part of most prescription drug plans until a few years ago. Today, a majority of states have laws requiring insurance plans that cover prescription medicines to cover contraceptives as well.

    9. Condoms
    Condoms are over-the-counter supplies, not prescription medication, so they are not covered by public or private health insurance.

    10. Abortion

    While some insurers provide coverage for abortions, at least a handful of states have passed laws restricting coverage of abortions on private insurance plans, except in cases of rape or when the mother’s life is at risk.

    Pages: 1 2

  • Category: Health Insurance

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