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Health Insurance: Understanding What’s In and What’s Out

By Expert HERWriter
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ins and outs of health insurance MonkeyBusiness Images/PhotoSpin

Understanding your health insurance is important for the health of your body and your wallet. For some basics on health insurance and the difference between in network and out of network providers, check out the article Know Your Insurance.

For help understanding the in's and out's of what’s covered by insurance, I turned to Dr. Archelle Georgiou, a health care executive and former Chief Medical Officer of UnitedHealthcare.

Her first advice? Read the Exclusions section.

Your health insurance policy is a contract between you and your insurance company. The exclusions listed in the policy are the services that will not be paid for by the insurance company.

Exclusions are a common feature in many types of contracts. When you purchase an insurance policy, you agree to accept all parts of the contract, including the exclusions. Keep in mind that if the exclusions were included in the policy, the price of your policy would be much higher.

Some exclusions are for specific procedures like bariatric surgery, artificial insemination, or acupuncture. One of the most common exclusions is for procedures that "are not medically necessary."

This means that if a surgery is required for well-documented medical reasons, it is likely to be covered by your insurance.

However, a surgery or procedure that is optional -- simply because it is your preference or for your convenience or peace of mind -- may not be covered if there are other alternatives that the insurance companies believes are just as effective and less expensive.

Breast reduction and eyelid surgery are common examples of surgeries that are denied because they are not medically necessary.

If you have a specific health condition, you’ll want to make sure the insurance policy you choose does not exclude coverage for that condition. In most cases, coverage for a particular item is included unless it is specifically listed in the exclusions.

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We value and respect our HERWriters' experiences, but everyone is different. Many of our writers are speaking from personal experience, and what's worked for them may not work for you. Their articles are not a substitute for medical advice, although we hope you can gain knowledge from their insight.