What Kinds of Things Won't Medical Insurance Companies Cover?

Despite the ever-increasing cost of medical insurance, the protection it offers is important for everyone. First of all, everyone is vulnerable to injury and illness, and medical care can be very expensive. Also, for those individuals with chronic or lifelong conditions, prescriptions and follow-up care can really add up. Although insured individuals have to pay part of their medical bills, they are not burdened with the full amount. However, having medical insurance does not mean that all medical services are covered. It is important to read one's contract thoroughly to avoid additional out-of-pocket costs.

Cosmetic Surgery

• Medical insurance companies do not provide coverage for services rendered that are considered to be cosmetic in nature. For example, plastic surgery for the purpose of improving someone's appearance (such as a breast enlargement or rhinoplasty) are not covered because there is no medical need to have these services. However, reconstructive breast surgery is typically covered for breast cancer patients who have a mastectomy. Also, surgery to repair a deviated septum may be covered if there is a medical reason for the surgery, such as chronic sinus congestion or breathing problems.

Acupuncture

• The insertion of needles into certain points on the body to alleviate symptoms of pain was founded by the Chinese. This practice continues to be used today for a variety of conditions. However, controversy exists in the world of Western medicine regarding the efficacy of acupuncture. As such, most insurance plans do not cover acupuncture. Medicare and Medicaid also do not provide coverage for acupuncture.

In Vitro Fertilization

• In vitro fertilization (IVF) is a method of reproduction for couples with infertility problems. The fertilization of an egg is performed outside of the womb and inserted into a woman's uterus. Because medical insurance companies are not required to provide coverage for IVF, they typically do not cover this expensive procedure---particularly because several attempts may be required to be successful. Other less-invasive procedures (such as intrauterine insemination and gamete intrafallopian transfer) may be covered in part, but the hormone treatments that accompany these strategies are frequently excluded by pharmacy coverage. However, many states require insurers to cover the costs associated with the diagnosis and treatment of any condition that results in infertility (such as endometriosis).

Pre-Existing Conditions

• Medical costs incurred for a pre-existing condition are not typically covered by health insurance companies. A pre-existing condition is any condition for which a consultation was sought, a diagnosis was made or for which treatment was obtained before the insurance coverage began. When enrolling in a new health plan, the lack of coverage for pre-existing conditions is generally not applied to individuals who were previously insured in another plan. However, if coverage under the previous plan ended more than 63 days before enrollment in the new plan, the pre-existing condition clause is applicable.

Not Medically Necessary

• Medical insurance companies will not cover any treatment or service that they do not feel is medically necessary. Therefore, even though a doctor may recommend that a patient should have a certain test or x-ray performed, this recommendation has to be approved by that patient's insurer before the expense will be covered. If the insurer does not believe there is a medical basis for the recommended procedure, they can deny payment. Insurers may also deny a request for services, such as surgery, and instead recommend a less-expensive alternative, like physical therapy.