Obesity, Learning Disorders, ADD and ADHD, Maternity Benefits

Below is a breakdown of specific exclusions from coverage found in a typical individual health insurance policy.

Limitations, Exclusions and Non-Waiver (cont.) B. Exclusions (cont.) [In addition to other general Policy exclusions from coverage, the Policy does not provide coverage for any of the following, all of which are specifically excluded]: 27. services, treatments, or surgical procedures rendered or performed in connection with an overweight condition or a condition of obesity or related conditions; 28. treatment or services for behavioral or learning disorders, Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD); 29. any professional fees or other medical expenses incurred as the result of an Injury which was caused or contributed to by an Insured racing any land or water vehicle; 30. any professional fees or other medical expenses incurred for the diagnosis, care or treatment of Mental and Emotional Disorders, Alcoholism and Drug Addiction/Abuse, except as provided in the Mental and Emotional Disorders, Alcoholism and Drug Addiction/Abuse provision; 31. routine maternity or any other expenses related to childbirth, except Complications of Pregnancy, including routine nursery charges, unless the optional Maternity Benefit Rider was purchased and is in force as of the date said expenses were incurred;

Obesity: Under this sample policy, medical expenses for the treatment of obesity are not covered. In short, they are paid for out-of-pocket. It is obviously not regarded as an illness, but there may be situations where certain aspects of treatment may become medically necessary even if the onset of the obesity is regarded as a willful, voluntary act. If the health of the Insured is at risk and there are non-experimental medical treatments available that are not for vanity purposes and appear to be the only option then available (in other words, it is too late to just adjust the diet), a good case can be made for medical necessity.

Behavioral and learning disorders: Behavioral and learning disorders are just not considered illnesses to be covered by a health insurance policy.

Maternity coverage: This is standard for maternity coverage to be available by purchase of a “Maternity Benefit Rider”. If this coverage was included in the policy, the insurance companies would be exposing themselves to what is called anti-selection, where people would buy the coverage when they were planning to have a baby. There would be no pre-existing condition exclusion unless the wife was already pregnant and all the other policyholders would be exposed to higher premiums to cover those people who elect to buy insurance when they have decided to have a baby.

*Wording may vary from contract to contract and from state to state.