Health Insurance Riders and Exclusions - The Basics

Health insurance can be a confusing area for anyone to navigate, with difficult concepts to understand for someone who is not well versed in insurance. One of the most confusing areas is health insurance riders and exclusions. Every company is different, although all must comply with federal, state, and local laws. However, the details of each policy's riders and exclusions vary widely from insurance company to insurance company. Even within a single company, coverage will vary from one plan to the next. So how is a novice supposed to learn about riders and exclusions if there are so many different options?

First, it would help to understand exactly what health insurance riders and exclusions are and what they are not. Exclusions cover health conditions, treatments, and other medical procedures that are excluded from coverage in whole or in part. Riders are changes to the standard policy. For example, a rider might specifically exclude treatments for a pre-existing condition in order for an otherwise uninsurable patient to get coverage. A rider might also feature changes to the standard policy such as capping a family's deductible at a certain amount no matter how many dependents are covered.

While each company has their own policies regarding health insurance riders and exclusions, there are some standards that apply to all or most companies. For example, typical exclusions from coverage include:

1. Pre-existing conditions
2. Cosmetic or plastic surgery
3. Infertility treatments
4. Co-ordination of benefits (to prevent duplicate payments for the same covered event)
5. Experimental treatments, procedures, or medications
6. Dental maintenance, treatments, or procedures
7. Injuries sustained during criminal activity, during times of war, while under the influence, or while serving in the military
8. Vision correction including eye exams, eyeglasses, contacts, or corrective surgery

Likewise, there are standards in terms of riders. Insurance policies must be written to comply with federal, state, and local laws. As such, most insurance companies write policies based on a standard insurance form. When an insurance company offers a customer or group of customers additional coverage or different terms, a rider must be written separately as an addendum to the standard form policy. Some common riders include:

1. Indemnity (doubling or tripling benefits for qualifying death or dismemberment)
2. Impairment riders (to specifically exclude a pre-existing condition)
3. Premium riders (skipping premiums during lengthy hospital stays and other premium-related changes)
4. Additional coverage for specific conditions, treatments, or procedures

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