What is a health insurance exclusion?
- By Willi Olsen
- Updated
An exclusion is a treatment or medical condition not covered by health insurance. Excluded treatments are listed in the policy, aren’t paid for by the insurer, and don’t count toward the excess. LifeCovered explains the fine print to avoid unexpected costs when they matter most.
Having helped hundreds of New Zealanders get health insurance, we’ve seen many people start a policy with a health insurance exclusion for a pre-existing condition.
If your insurer adds an exclusion for something you’ve had in the past, like an old injury or medical condition, that doesn’t mean it’s a permanent exclusion. If things improve, and you are symptom and treatment-free, you can ask the insurer to review your application. Sometimes, with the correct medical info, they’ll agree to remove the exclusion altogether.
Not sure if your exclusion can be removed? Flick me a message and I’ll help you check.
Common health insurance exclusions
All health insurance plans have common exclusions, but conditions can vary from one insurer to another. While the best-known exclusions are “pre-existing conditions”, there are many other items that are not covered by health insurance products and that you should beware of: especially lesser-known exclusions that can cause outrageous medical bills.
Substance abuse or self-inflicted injuries
Treatment for drug or alcohol abuse is usually not covered by health insurance. So if you need to go to rehab or end up in hospital because of substance use, you’ll have to cover those costs yourself.
The same goes for suicide and self-inflicted injuries — these aren’t included in your policy benefits. If someone dies by suicide or harms themselves while attempting it, the insurer won’t pay out a claim under the policy.
Childbirth and related expenses
Maternity cover isn’t something you get by default with most private health insurance, and you can’t just add it on by itself. It only comes as part of a plan that includes inpatient or inpatient plus outpatient cover.
Even then, the benefits are pretty limited. What you can claim back for things like childbirth, scans, and prenatal care often covers just a small portion of the total cost. So if you’re thinking about starting a family, it pays to check what’s actually included and be ready to cover the rest yourself.
ACC covered healthcare services
ACC provides no-fault injury cover for everyone in New Zealand. The New Zealand public healthcare system covers all New Zealand residents for acute care and some elective treatment.
Private health insurance plans are designed to complement the services provided by ACC and the New Zealand public healthcare system.
That’s why private health insurance doesn’t cover things like emergency care, accidents, or injuries from treatment or work because ACC is responsible for those. But ACC doesn’t always cover the full cost of treatment. If that happens, you might be able to claim the difference through your policy under what’s called an ‘accident and treatment injury top-up’. Just check your policy wording to see if that option’s included.
Review an health insurance exclusion?
If your policy has an exclusion and the health issue that caused it is no longer a problem, don’t just leave it sitting there. Get in touch with your insurer and ask for a review — or if you’re with LifeCovered, flick us a message and we’ll handle it for you.
Need help finding the right cover?
Call 0800 259 925 or book a time we’re here to make insurance simple and stress-free.
At LifeCovered, our job is to help you choose wisely. We’re paid standard commissions already built into your premium, so our advice is expert, unbiased, and completely free to you.
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