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Experimental Procedures, Eye/Ear Treatments, Alcohol/Drug Use, Self-Inflicted Injury

UPDATED: February 24, 2015

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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]:

12. experimental procedures or treatment methods not approved by the American Medical Association or other appropriate medical society;

13. eye refractions, eyeglasses, contact lenses, radial keratotomy, lasik surgery, hearing aids and exams for their prescription or fitting;

14. Cochlear implants;

15. any professional fees or other medical expenses incurred by an Insured which were caused or contributed to by the Insured being intoxicated by alcohol or under the influence of any drug, narcotic or hallucinogens unless administered on the advice of a Provider, and taken in accordance with the limits of such advice;

16. intentionally self-inflicted injury, suicide or any suicide attempt while sane or insane;

Experimental treatment: As new treatments for various conditions are developed, insurance companies will conduct experimental reviews of those treatments. By reviewing medical studies and opinions from medical experts, the insurance company attempts to determine the safety and effectiveness of new medical treatments. Therefore, if you are about to undergo a unique medical treatment, you first step is to find out if your insurer will cover it. If other insurers cover it, ask your company to talk with the other companies' experts. You may be able to get it covered.

Drug treatment: Your insurer can deny claims for injuries associated with the use of alcohol, drugs, narcotics or hallucinogens. Note this provision requires the medical expenses to be caused by or contributed to by use of the drug. For example, if you are under the influence of drugs and are a passenger in a car that is hit by another car and you incur medical expenses as a result of injuries from the accident, the exclusion would not apply. You would be covered. In these cases, your company has to prove two things: (1) that you were intoxicated or under the influence, and (2) that it caused or contributed to your medical expenses.

Self-inflicted injuries: Benefits are not paid self-inflicted bodily injury while sane or insane. If you at the time of injury could not foresee the possibility of injury, the harm may be considered accidental and this exclusion would not apply. But, because of the phrase, "while sane or insane", insanity is not an excuse for avoiding the exclusion on the basis that an insane person could not intentionally injure himself.

Suicide: This same rule applies to suicide. The addition of the "while sane or insane" wording usually removes the necessity for the company to show that the Insured had sufficient mental capacity to intentionally kill himself. In spite of this, courts are hesitant to call a death suicide and will look for every reason to call it accidental.

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

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