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What Diseases Are Not Covered By Health Insurance?

What Diseases Are Not Covered By Health Insurance? | Very Good Coverage

Under Obamacare, you cannot be denied coverage based on your pre-existing conditions. However, some medical services aren’t covered in health insurance.

According to a study by The Kaiser Family Foundation, an estimated 54 million Americans aged, which is 27% of Americans, have pre-existing conditions that would make them uninsurable in the past. Thanks to Obamacare, it’s now illegal for health insurance companies to deny you medical coverage or increase their rates based on your gender or pre-existing conditions. But even with that, there are still medical services that are generally not covered in health insurance.

Some services are typically not covered by most health insurance plans. They include cosmetic procedures, fertility treatments, off-label prescriptions, and the use of new technology, products, or services. The idea here is that it’s much difficult to obtain medical coverage for anything that’s potentially seen as “test procedures.”

In this brief guide, we’ll take a look at the services that most health insurers decline to cover and how you can get your way around these denials.

Cosmetic Procedures

Many medical services that are meant to improve an individual’s exterior appearance such as plastic surgery, some dermatological procedures, and overall cosmetic procedures are generally not covered by many health insurance companies. This is because these procedures are either deemed to be experimental or medically unnecessary.

Most health insurance companies categorize these procedures as purely “cosmetic” and not medically necessary. As such, surgical treatments including liposuction, nose jobs, and butt enhancement are generally not covered by many health insurance companies.

Again, most health insurance companies will not cover these cosmetic procedures because they’re deemed experimental and are very expensive. They’re also invasive and not safe and many health insurance companies believe that there could be more effective and safer alternatives.

This, however, doesn’t mean that you cannot get coverage for your cosmetic procedures. With proper research, you’ll find several health insurance companies that are willing to take the risk and quote a price for covering you for these procedures.

The only problem is that cosmetic procedures are generally one-off procedures so their premiums might be quite high, especially taking into account that they’re typically risky surgical procedures.

What to Do

If your health insurance company refuses to cover your cosmetic procedures, you should call your doctor and have him/her prove to the insurance company that the cosmetic procedure is necessary. Of course, your doctor will have to provide additional evidence that cosmetic surgery is necessary before your insurer can accept the claim.

You also have to make sure that the cosmetic procedure is explicitly not covered or accepted by your health insurance policy. If your health insurance company still refuses to cover your cosmetic procedure, you consider possible alternative treatments or forego the procedure altogether.

Off-Label Drug Prescriptions

One of the biggest problems in health insurance is that most insurance companies will not pay or reimburse for off-label drug use. In fact, many insurers will not pay if the off-label drug is expensive or if it’s used in a way that is not listed on the approved drug label. The idea here is that these drugs are used as experimental and not medically necessary.

But what exactly is an off-drug prescription? Well, many new drugs in the United States are usually tested in clinical trials before they’re approved by the US Food and Drug Administration (FDA). When the FDA approves that the drug is safe and can be used by the public, the manufacturer is required to create a drug label.

Of course, this label isn’t the normal label that is stuck on the bottle but rather a report on the very specific health problems that this drug treats. This report has to be approved by the FDA and should be available to all health professionals including health insurance companies.

With that in mind, using the drug in a way that’s completely different from what is described in the FDA-approved label means that you’re using the drug off-label. Using the drug off-label includes:

  • Giving the drug in a different way
  • Giving the drug in a different dose than in the FDA-approved label
  • Using the drug to treat a different disease or medical condition

It’s, therefore, not uncommon to find out that your insurer won’t cover, pay, or reimburse for the use of off-label drugs. This is because the use of off-label drugs isn’t regulated. While some drugs may be used to treat diseases that are not listed on the label, it’s more than likely that your health insurance company will decline to pay for these drugs on the basis of off-label drug use.

What to Do

There’s no denying that the process of getting your health insurance company to reconsider its decision to exclude off-label drugs can be very complicated. The best thing to do before buying any drug is to ensure that you have up-to-date insurance information. This should include the drugs that are included on the label.

You can also confirm whether the pharmacy where you bought the off-label drug is on your insurer’s network. Most health insurance plans that have Medicare Part D plans often encourage policyholders to use a specific network of pharmacies for their prescriptions. This can make it a lot easier to resolve any dispute regarding off-label drug prescriptions.

You have to keep in mind that your insurer will either deny reimbursing for off-label drugs that are bought outside its network of pharmacies or require you to pay more. Better still; just make sure that you do not use off-label drugs. Instead, you can choose the right drug at a better price. And if you have to use off-label drugs, you can forget about being reimbursed by your health insurance company.

Infertility Treatments

Even though health insurance companies are expected to cover all the testing required in making an infertility diagnosis, they generally do not cover the costs of the actual fertility treatments.

It doesn’t matter whether the infertility treatment is iatrogenic or natural; many health insurance companies refuse to cover infertility treatment on the basis that they’re elective procedures and not medically necessary procedures.

Many people in the United States including men and women require fertility treatments. However, these treatments are generally inaccessible to most of them due to the high costs that are involved. While 15 states across the country require health insurance companies to cover some fertility treatments, there’s still a huge gap given that the remaining states do not stipulate the same in their constitutions.

With that in mind, fertility treatments remain out-of-pocket expenses for many Americans. Most of the fertility treatment costs are on the north of $10,000 depending on the services offered.

What to Do

The most important thing is to read your health insurance plan carefully and find out whether you can be eligible for partial coverage for the costs of fertility treatments. Just don’t assume that your insurer will not cover these costs.

Again, you can choose to tap into the Health Savings Accounts (HSA) or the Flexible Spending Account (FSA) to help you offset the high costs of fertility treatments. HSAs allow you to put aside a portion of your pre-tax income to cover your medical expenses while FSAs are meant to set aside part of your pre-tax income to help in covering specially designated expenses.

You can also participate in clinical research trials as an option for paying for fertility treatments. There are discounts for such trials but you must read the fine print of the agreement. Make sure that you clearly understand your responsibilities and what the clinic is offering before signing.

New Technology, Products, and Services

It’s important to keep in mind that you may not be covered for using new technology, products, and services. Health insurance companies are generally slow in covering or even adopting new technology, products, and services until their medical benefits to consumers are proved beyond a reasonable doubt.

What to Do

There are special cases where health insurance companies can make exceptions and cover the use of new technology, products, and services. You can get coverage if it has been proven that the new technology offers additional benefits than what’s already in existence. Your doctor will be required to prove why the new technology or product is more beneficial.

You can also get partial coverage for new technology and products. The most important thing is to discuss the coverage with your health insurance company and reach a consensus on what they can cover and what can be excluded from that particular coverage.


Greg McKnight

Read more about Greg McKnight

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