Expenses Not Covered Under Health Insurance Policies

These are two specific exclusions from coverage found in a typical individual health insurance policy.

Covered Expenses consist of the items and services listed in the policy in the sections entitled: “Participating Provider Services Subject to Co-Pay,” “Non-Participating Provider Services Subject to Co-Pay,” “Participating Provide Services Subject to Calendar Year Deductible”, “Non-Participating Provider Services Subject to Separate Deductible for Non-Participating Providers and Miscellaneous Benefits”. Expenses for these listed items must actually be incurred by the insured and medically necessary.

Medically necessary defined: The policy defines “medically necessary” as: any applicable confinement of an insured, as well as other diagnostic test, laboratory test, examination, surgery, medical treatment, service or supply listed therein that is provided to an insured:

1. by or at the appropriate order, or upon the approval of a provider;
2. for the medically recognized diagnosis or care and treatment of an injury or sickness;
3. in a manner appropriate and necessary for the symptoms, diagnosis or treatment of such injury or sickness;
4. according to and within generally accepted standards for medical practice;
5. in the setting and manner appropriate for the treatment of the injury or sickness;
6. not primarily for the convenience of an insured, family or a provider; and
7. not investigational or experimental in nature.

In other words, a treatment is medically necessary if it is ordered by your doctor for a medically recognized diagnosis, and the treatment and setting for the treatment is the general protocol for the symptoms or illness and not merely experimental. The treatment must be reasonable and appropriate for the sickness, which leaves it somewhat open to discussion and interpretation.

If you have been denied coverage because the company has deemed it not medically necessary, with your physician’s help, you have a chance of persuading your insurer otherwise by appealing their denial.

*Wording may vary from contract to contract and from state to state.