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International Service, Voluntary Abortion, Services Provided by a Family Member; Excluded Conditions, Illegal Occupation or Activity

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

(Typical wording*):

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]:

17. medical expenses incurred while serving in one of the branches of the armed forces of any foreign country or any international authority;

18. volunteer abortions;

19. services Provided by You or a Provider who is a member of an Insured's Family;

20. any medical condition excluded by name or specific description by either this Policy or any riders, endorsements or amendments attached to this Policy;

21. any loss to which a contributing cause was the Insured's being engaged in an illegal occupation or illegal activity;

International service: If you as the individual insured are working for the armed forces of a foreign country, don't expect coverage. Similarly if you are working for an international authority, such as the U.N.

Volunteer abortion: The medical expenses incurred in connection with a volunteer (elective) abortion are not covered. An abortion would not be voluntary if done against the Insured's will or while an Insured is under sedation and the doctor determines that it is necessary to protect the health or life of the insured patient. In virtually all other instances it would be voluntary.

Services by a family member: Services rendered by a family member are not covered. It is presumed that "in-family" services are free or at a substantially reduced rate, in which case your insurance provider would be paying benefits for expenses for which your health care provider did not charge you. "Family" means the spouse, son or daughter, brother or sister, parent, grandparent or grandchild of an Insured.

The purpose of this provision is primarily to make it crystal clear that conditions excluded in riders, endorsements and amendments to the policy are not covered. At the time of application for the policy, the company may have learned of existing health conditions of policyholders that it could not cover and still issue the policy. Therefore, your health insurance company issued the policy with a rider, endorsement or amendment that specifically excludes coverage for medical expenses for those conditions. If the policy has been in force for a number of years those exclusions may be a dim memory, but they still apply.

Illegal activity: If you, the Insured, are engaged in an illegal occupation or illegal activity, any medical expenses caused by you engaging in this activity will not be covered. Even without this provision some courts have held that, as a matter of public policy, no benefits should be payable when the Insured's injury, and resultant medical expenses, are caused by the Insured's criminal wrongdoing. In any case, for this exclusion to apply, the illegal activity must cause the medical expense. If a person's occupation is illegal drug dealer and he slips on the wet tile around his swimming pool while relaxing on a Sunday afternoon and breaks his wrist, requiring medical treatment, the exclusion does not apply because his illegal occupation did not cause him to fall, injure himself and incur medical expenses. If, on the other hand, he is engaged in an illegal sale of drugs in a warehouse that goes bad, gun fire breaks out and, while escaping, he falls and breaks his wrist, the exclusion does apply and the resultant medical expenses would not be covered.

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



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