Aviation, Cosmetic Surgery, Sterilization Fertility Treatment, and Sex Change

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

 

(Typical wording*):

Limitations, Exclusions and No-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]:

22. medical expenses incurred while participating in aviation activities, except as a fare-paying passenger traveling on a regularly scheduled commercial airline flight;

23. cosmetic surgery, except for Medically Necessary cosmetic surgery performed under the following circumstances: (a) where such cosmetic surgery is incidental to or following surgery resulting from trauma or infection to correct a normal bodily function; or (b) such cosmetic surgery constitutes Breast Reconstruction that is incident to a Mastectomy;

24. voluntary sterilization, reversal or attempted reversal of a previous elective attempt to induce or facilitate sterilization;

25. fertility hormone therapy and/or fertility devices for any type fertility therapy, artificial insemination or an other direct conception;

26. any operation or treatment performed in connection with sex transformations or any type of sexual dysfunction, including complications arising from any such operation or treatment;

Aviation: You should be aware that the aviation exclusion has been held by courts to apply not only to obvious things such as crop dusting, flying experimental aircraft, stunt flying and recreational flying, but also to hang gliding, water ski kite flying and sports parachuting. On-demand taxi service has also been held subject to the exclusion because it, like recreational flying, is not a regularly scheduled commercial airline flight. The bottom line: insurance companies recognize that commercial airline flight is very safe and, therefore, insurable. Not so for any other type of air activity or travel.

Cosmetic surgery: Health insurance companies are not in the business of paying for procedures to make you look better. So if you don't like the way you look, don't expect the insurance company to ante up for changing your appearance to satisfy your vanity.

On the other hand, cosmetic surgery that is part of reconstructive surgery after you have been disfigured by a disease or injury is very likely covered. This is a fairly subjective area, subject to the judgment of the claims analyst at your insurance company. If you have some surgery that needs to be done to correct a disfigurement, even if it is a congenital birth defect and not caused by injury or sickness, you should present your case to the insurance company. They may cover it if it does not seem to be vanity surgery like breast implants, tummy tucks, removing facial wrinkles, etc. Your insurer will cover breast reconstruction incident to a mastectomy for the specific purpose of achieving breast symmetry. While this is done purely for the sake of appearance, it is done to restore to what you looked like before the trauma of the mastectomy. This is regarded as medically necessary.

Sterilization: It is generally presumed that sterilization is not medically necessary. It is elective in nature and is usually done for convenience – to avoid the all that goes with having children. If an Insured can make an argument for the medical necessity of sterilization, your company may consider covering the cost.

Fertility treatment: It is difficult to imagine a scenario where fertility treatments, artificial insemination or other direct conception is medically necessary because the underlying purpose, to produce children, is not medically necessary.

Sex change: It may be possible to develop an argument that a sex change procedure is Medically Necessary, but even if you get over that hurdle, it is likely not covered because it is still regarded experimental in nature.

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