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What are the most common exclusions in your health insurance plan?
Life can be unpredictable. It’s not uncommon that your doctor suggests a course of treatment, and you comply, only to find out that your insurance plan only pays for a portion of the price or none at all. Imagine how disappointed and upset you would be. This can be a massive barrier to you receiving the care you need.
Though health insurance companies have been trying to improve transparency, there are still countless pitfalls, typically resulting in a lack of price transparency in the medical and insurance field. You could be asking both parties for pricing information. However, the answers are usually “it depends”. Fortunately, this Pacific Prime Thailand article tells you what is and isn’t included in a typical health insurance plan.
What does health insurance typically cover?
You don’t have to worry about footing the bill for the following procedures. This section gives a snapshot of what is typically included in your health insurance plan.
- Most doctor and hospital visits
- Prescription drugs
- Wellness care
- Medical devices
What doesn’t your health insurance typically cover?
Each health insurance plan is different depending on the insurer and the country. However, this is a list of services most commonly excluded in all healthcare insurance. See our easy-to-digest infographic on the 8 most common health insurance exclusions.
1. Pre-existing conditions
Did you struggle with an existing injury or illness before securing a health insurance plan? In that case, you might have what insurers call a pre-existing condition. An example would be chronic diseases or a heart condition. These are not covered by most insurers. However, some insurers place premiums or waiting periods to cover these conditions.
2. Behavioral and personality disorders
These refer to mental disorders, such as attention deficit hyperactivity disorder and conduct disorder.
3. Fertility treatment
Fertility treatments, such as In Vitro Fertilization and other Assisted Reproductive Technology (ART) treatments are usually excluded. Nonetheless, certain countries provide plans that cover fertility treatment with a number of caveats, such as a long waiting period.
Note: most health insurers are required to pay for all necessary testing leading up to the infertility diagnosis.
4. Sleep disorders
Insomnia, sleep apnea, and narcolepsy are examples of sleep disorders that are excluded from cover.
5. Specific scenarios listed in most health plans as exclusions
These include but are not limited to illnesses and injuries sustained due to natural disasters, participation in illegal activities, and self-inflicted injuries.
6. Cosmetic or elective procedures
Cosmetic or elective procedures are not considered to be medically necessary. As a result, they are not covered by insurers. A few examples would be plastic surgeries and certain dermatological treatments.
7. Obesity
This includes both the diagnosis process and treatment of obesity. It’s important to note that some policies may cover conditions such as gastric banding if the beneficiary has a body mass index of 40 or more.
8. Acquisition of an organ
The costs of the entire process of organ acquisition: donor search, typing, harvesting, transport, and administration costs are excluded in all insurance plans.
9. Off-label prescriptions
Off-label prescribing refers to using a drug approved by the Food and Drug Administration (FDA) to treat a condition different than your own. This is incredibly common and happens in one in five prescriptions in the United States. In Thailand, some off-label drugs are on the National List of Essential Medications. However, some insurance companies might reject reimbursing these off-label uses.
10. Brand new technologies or products
Covering the costs of new technologies or products can be a lengthy process. First, there needs to be proven benefits over older treatments. Second, they tend to cost more. Thus, insurance companies are unlikely to take the risk.
What can you do if your health condition isn’t covered?
Despite the long list of conditions not covered by most insurers, they do make the occasional exceptions. So, what can you do if your claim is denied? There are several actions you could take.
Get coverage for new treatments
Prove to your insurance company that the new technology or product is more effective. Then, discuss your coverage with your insurer. If this negotiation is successful, you will have partial coverage for your treatment.
Buy add-on coverage
Add-on coverage refers to buying additional policy features for a specific covered benefit. For instance, most basic health insurance plans don’t include dental and vision coverage. To receive those benefits, you will need to buy these optional coverages.
Appeal a denial
Depending on your prognosis, you can contest a denial by your insurer. Avoid this pitfall with a pre-approval. You or your doctor should contact your insurer before you even receive care from an in-network hospital. Make sure all components of your treatment are covered, from lab tests to anesthesiologist fees.
Keep in mind that most insurers have an in-network of healthcare providers they have contracts with. In other words, if you’ve received out-of-network care, your treatment will not be reimbursed.
Best health insurance in Thailand
A comprehensive health insurance plan ensures that you can comfortably pay for all medical treatments no matter what life throws at you. Why not go one step further with an international health insurance plan? With this plan, you can be sure to receive the best medical treatments no matter where you are in the world.
Pacific Prime Thailand has over two decades of experience in the insurance industry. We work closely with the most reputable insurance partners. Feel free to contact us for any insurance-related questions – we’ll be more than happy to put together the perfect plan for you!
Serena earned her Bachelor’s Degree in Psychology from the University of British Columbia, Canada. As such, she is an avid advocate of mental health and is fascinated by all things psychology (especially if it’s cognitive psychology!).
Her previous work experience includes teaching toddlers to read, writing for a travel/wellness online magazine, and then a business news blog. These combined experiences give her the skills and insights she needs to explain complex ideas in a succinct way. Being the daughter of an immigrant and a traveler herself, she is passionate about educating expats and digital nomads on travel and international health insurance.
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