What Health Insurance Doesn't Cover

Preventive care and pre-existing conditions top the list.

Not all medical procedures are covered under standard health insurance policies. Most policies exclude coverage for what insurers consider preventive care, such as routine physicals, contraception and cancer screening. Policies often exclude coverage blood tests and x-rays unless they occur immediately before you are admitted to a hospital. Payments for eye exams, chiropractic or acupuncture treatment, and non-prescription medications or vitamin supplements are often excluded from many policies, although they may be available if an additional premium is paid.

Most health insurance policies will contain some provision about pre-existing conditions. Each policy has its own definition of a "pre-existing condition" but generally it's defined as a health problem that existed before the insurance coverage was purchased. The contract designates a particular length of time, such as the year before the policy was purchased, as the relevant time period. Any illnesses or injuries that occur after the policy was purchased which can be traced back to a condition occurring within this time period will be excluded from coverage.

In many cases, however, this exclusion is only temporary. For example a "12/12" pre-existing condition clause means that the policy will exclude coverage of an illness or injury that occurred within 12 months of purchasing the policy for the first 12 months that the policy is in effect. After that, the policy pays for treatment of the pre-existing condition just as it would for any other covered medical problem.

One controversial exclusion contained in the majority of health insurance policies bans insurance company payments for experimental treatments. In some cases, incurable diseases such as bone and liver cancer may only be treatable with experimental procedures. Several court battles have been waged by those suffering from incurable diseases against insurers, seeking a court order requiring the insurance company to pay for these treatments. The results of these suits has been mixed. However, some health insurance companies now allow members to pay an additional premium for coverage of experimental cancer treatments and transplant procedures. While this insurance may cover 80 percent to 100 percent of the cost of these procedures, "stop-loss" provisions in the policy may limit the total amount of the insurer's liability to a specified amount, such as $500,000 or $1 million.