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Exclusion Rider for Individual Health Policy - how does it work?
Old 08-30-2010, 03:13 PM   #1
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Exclusion Rider for Individual Health Policy - how does it work?

We (DH & I) recently applied for an Individual Health Insurance policy. We had been uninsured for the past 18 months and decided to go with High-deductible ($10,000) HSA eligible policy, just in case. Completely new to the Individual Health market after FIRE at about 40. Been group insured always prior to that.
As part of the Application Process the insurance company has come back with an Exclusion for Tinnitus that I was diagnosed with it in 2007 but no treatments / problems since then.
It says no coverage for "Tinnitus including any treatment, medication(s) or operation for or complications thereof. Removal of this rider is not automatic but can be reviewed for removal as of 9/21/2012".

A couple of simple questions so I am sure I understand Exclusions.
Does that mean if I do end up seeing a doctor or doing tests related to it at some point, the amount will not count towards deductible? Also would I get the "Network Discount Rate" on these, if needed?
I am concerned about "....or complications thereof...." language since it is so vague. Any claim related to Ear, Head, Brain, etc can potentially be denied with this clause?
Chance of Tinnitus coming back to bother me are slim (been free of it for almost 3 years), but I need to understand what I am signing up for.
Thanks!
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Old 08-30-2010, 07:23 PM   #2
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Sounds like Humana, just guessing based on the wording of the rider. If it is excluded, there is no network discount for any services and nothing counts towards the deductible. Another company may not put the same exclusion on the policy if it's been more than 3 years. You might want to consider United Healthcare (a.k.a. United Health One/Golden Rule) if this was a Humana policy. UHC also includes as a standard part of the policy a deductible credit that will reduce your deductible by 20% each year that you do not hit the deductible, up to a max reduction of 50%. Their rates are probably similar. UHC also doesn't require a 12-month waiting period on pre-existing conditions if they are fully disclosed and not specifically excluded as you have in this offer.
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Old 08-31-2010, 04:55 PM   #3
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I would be willing to bet that if you got an ear ache they would try to not cover it. BCBS offered me a policy that had a rider permanently excluding anything headache related. I kindly declined their policy and went with United Health Care who obviously was not concerned about my migraines.
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Old 08-31-2010, 05:44 PM   #4
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Originally Posted by stargazer08 View Post
I would be willing to bet that if you got an ear ache they would try to not cover it. BCBS offered me a policy that had a rider permanently excluding anything headache related. I kindly declined their policy and went with United Health Care who obviously was not concerned about my migraines.
That sounds backwards....BCBS is usually the company that doesn't exclude anything and UHC usually excludes almost everything, especially migraines. Strange.
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Old 08-31-2010, 10:42 PM   #5
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Originally Posted by dgoldenz View Post
You might want to consider United Healthcare (a.k.a. United Health One/Golden Rule) if this was a Humana policy. ... UHC also doesn't require a 12-month waiting period on pre-existing conditions if they are fully disclosed and not specifically excluded as you have in this offer.
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Originally Posted by dgoldenz View Post
That sounds backwards....BCBS is usually the company that doesn't exclude anything and UHC usually excludes almost everything, especially migraines. Strange.

dgoldenz, you write that I should consider United Healthcare since they cover pre-existing but then also write UHC usually excludes almost everything... not sure I understand the difference.
Please clarify.
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Old 08-31-2010, 10:53 PM   #6
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dgoldenz, you write that I should consider United Healthcare since they cover pre-existing but then also write UHC usually excludes almost everything... not sure I understand the difference.
Please clarify.
If they approve the policy without the exclusion, they will cover it from day one. Most companies require a 12-month waiting period regardless of specific underwriting exclusions. Here is the wording from the brochure:

"Pre-existing conditions will not be covered during the first 12 months after an individual becomes a covered person. This exclusion will not apply to conditions that are both (a) fully disclosed to Golden Rule in the individual's application; and (b) not excluded or limited by our underwriters"


It's possible they may exclude the condition too, but if they don't, it would be covered.
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