Health insurance is an extremely complicated process, and very much a hot topic these days.
Even if you’ve read your enrollment brochure cover-to-cover, it’s still possible to miss some of
the details of your coverage. With so many plans, exceptions, restrictions, and limits, it’s easy for
your insurance to catch you off guard when it refuses to cover a procedure.
Most procedures are covered by most plans – emergency care being the most obvious. A general
rule of thumb is that insurance companies tend to restrict coverage to those situations they deem
“medically necessary” or life-threatening emergencies. That said, there are still some cases
where a seemingly-emergency procedure is denied coverage.
The purpose of this list is not meant to be exhaustive, but to give you an idea of some of the most
common procedures insurance won’t cover, as well as provide a brief explanation why.
1. Cosmetic Surgery
This one is pretty obvious. In very few cases are breast implants, liposuction, or facial
reconstruction considered “medically necessary” by your insurance provider. Regardless of how
some people may feel about that decision, it’s not likely to change anytime soon. Note that this
covers most “elective” surgeries and procedures for weight loss, regardless of doctor
Despite the genuine medical benefits to Lasik surgery, insurance companies usually deem them
unnecessary as corrective lenses and ophthalmology are much more accessible, and affordable.
In-vitro, no matter the cause of infertility, is an expensive procedure that insurance will almost
never cover. The rationale for this, and many other procedures, is that insurance focuses on
emergency, and unexpected situations. Since infertility treatment is “elective” it’s not covered by
most providers. It’s worth checking with your insurance, though, since 30% of plans do cover
4. Experimental and Off-Label Treatments
Medical research is constantly marching forward, and doctors are always interested in new uses
for old treatments. Unfortunately, if your doctor offers you an ‘off-label’ use for a medication –
meaning a prescription being used for treatment beyond its medically authorized use – for
experimental treatment, your insurance company usually won’t cover this.
The same goes for new technologies. Unless an early adopter starts covering these services –
usually Medicare – then other companies will likely wait the trial-phase out, only covering new
technologies after they’ve had a consistent track record for success.
5. Organ Transplants
Now for the big one. Even when you are in a life-threatening situation and need an organ
transplant to survive, insurance doesn’t like to cover them. While you should check your health
policy to confirm, this may mean you end up paying out of pocket for an emergency transplant.
Currently, only 45% of companies cover this expense.
Whatever we may think of this decision, or its reasoning, insurance companies point to the
complex nature of organ donation and procedures to explain that setting up a uniform cost is
beyond their abilities. What’s worse is that these procedures are sometimes classified as elective
surgery, and yes, even in emergencies.
6. Chronic Disease
Another tough pill to swallow, insurance usually won’t cover the infamous “preexisting
conditions” of diabetes, heart disease, or complications relating to obesity. This means that
chronic treatment for problems with these diseases may have to come straight out of pocket –
Regardless of any other considerations, from the insurance standpoint, it’s not hard to see why
they won’t cover this. Health risks from these diseases are responsible for almost 75% of
American healthcare cost. If companies covered these procedures, they’d be flat broke.
In the future, however, there may be further legislation opening up annual caps and restrictions,
which, if nothing else, allow companies to cover some of the cost of chronic illness.
7. Dental Cosmetics
Braces, augmentation, tooth alignment – unless your dentist deems these as a serious health
concern, your insurance company likely won’t cover any of it as they fall firmly into the
What to Do When Insurance Won’t Cover Costs
It can feel like a punch in the gut when your insurance won’t cover costs – especially for a
medical emergency. But you do have a few options for getting through it in one piece.
Talk to Your Doctors
Before you go through with a procedure, make sure you’ve talked to your physician about
coverage. This usually means having to relay between your doctor and your insurance company.
It’s vital that everyone knows what’s needed for coverage to apply – especially in gray areas
where your doctor feels a procedure is necessary, but your insurance is skeptical.
Depending on who performs the procedure, they may offer sliding scales for payment depending
on income, and whether or not your doctor deems it medically necessary. It’s fair to say,
however, that cosmetic surgery is still going to cost you full price.
Don’t Forget Preapproval
Many procedures are covered, but only if you’ve confirmed with your insurance why you’re
getting the operation, and whether or not it’s medically necessary. Preapproval usually follows a
template set up by your provider, and you should always double check before undergoing any
Hospitals know full well that medical bills are expensive. Most doctors, surgeons, and nurses
aren’t any happier than you are about the costs of the healthcare industry. That said, they need
money to operate, and most facilities prefer some payment to no payment.
Interest-free payment plans are usually available, and some hospitals provide financial assistance
for patients in need. You should also check for prompt pay discounts – if you pay your fees
immediately, some hospitals may cut part of your debt.
Pay Your Bills
Whatever you do, don’t ignore your medical bills. Aside from the insurance companies and
hospitals, ignoring your bills can land you in serious credit trouble. Unless you have no other
possible options, you should also try to avoid paying with credit or taking out a loan to pay for
medical care. Taking on debt to pay for healthcare is a lose-lose for you and may take years to
pay off – and even then, it may wreck your credit in the process.