What are “definitions,” “benefits,” “limitations,” and “exclusions?”
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UPDATED: Feb 24, 2015
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Every health insurance policy or health plan agreement or evidence of coverage is divided into different sections. For instance, a section may identify “benefits” as including services by a physician or surgeon, hospital services, nursing services, medical equipment and the like. This section, in effect, gives a broad outline or index of the benefits covered by the insurance or plan. Sometimes within the same section, but also sometimes in a separate section, there are specific “definitions” of benefits or related terms. For instance, the term “physical therapy” may be defined as “medically necessary therapy ordered by a physician and provided by a registered physical therapist.” The benefit section may list physical therapy as a benefit, as an example, by identifying it as “acute physical therapy.” The term “acute” then may be defined in the policy as being only for a period of 60 days following injury or onset of illness. Then in the “limitations” section of the policy there may be a further qualification of acute physical therapy as only being authorized if it is anticipated that the therapy would result in substantial improvement of the condition within 60 days, or there may be a statement that the therapy is limited to a total dollar amount of charge, such as $1,000 or $5,000. Further, in the separate “exclusions” section there might be a statement that specifically says that any physical therapy beyond 60 days would be excluded or any physical therapy that would not result in substantial improvement of a condition within 60 days is not a covered benefit. In summary, this typical example concerning physical therapy shows that benefits, definitions, limitations and exclusions operate together to define what is covered and what is not covered under the policy or plan.