exclusion

What is an exclusion?

An exclusion is a provision within an insurance policy that eliminates coverage for certain acts, property, types of damage or locations. Things that are excluded are not covered by the plan, and excluded costs don’t count towards the plan’s total out-of-pocket maximum.

In the past, individual health insurance policies frequently contained exclusions for pre-existing medical conditions. But since 2014, as a result of the Affordable Care Act, all new individual major medical policies have been guaranteed issue and pre-existing condition exclusions are no longer allowed.

However, these policies — like all health insurance policies — still contain numerous blanket exclusions that apply to all policyholders and are detailed in the policy documents. Some examples of often-excluded services include cosmetic surgery, vasectomies, weight-loss drugs and bariatric surgery, abortion, acupuncture, dental care on a health insurance policy, etc. But some policies cover services that others exclude, so there’s variation from one plan to another.

And some states have mandates that require all state-regulated plans to cover certain services — examples can include abortion, weight-loss drugs, vasectomies, and infertility treatments — so this also varies from one state to another.