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Although most of us are aware of the importance of taking care of our physical health, sometimes we tend to forget about another equally basic one: mental health. A point at which having a psychiatry service in our health insurance can be a great relief in the face of any problem. We tell you the policies that include it.
What are the most common exclusions in health insurance?
When we talk about limits, we do so both in general terms and those that affect certain specialties, considering a series of assumptions that are not covered in the care they provide: for example, you cannot access dialysis treatment if you suffer from an illness chronic renal. Or you can access plastic surgery, but only in certain cases, such as post-mastectomy breast reconstruction.
What are the exclusions that we can find in health insurance?
The general exclusions to insurance coverage are usually practically the same in any health condition, exceptions aside -which we will see later-. We are talking about the following coverages, such as those usually excluded in health insurance:
- Health care in the case of pre-existing diseases, pathologies and injuries, or sequelae or consequences of an accident prior to taking out the insurance. Hence the importance that companies give to the questionnaire that all users must complete, stating whether they suffer from any major health problem, such as a chronic disease. It may depend on this questionnaire that the insurer excludes certain coverage for the insured in the particular conditions of the policy subscribed.
- Health care related to diseases, accidents, injuries, malformations or defects that are a consequence of: war conflicts, terrorist acts, nuclear radiation, work or professional accidents, sports practice, traffic accident, etc. These are situations that are (or may be) covered by other types of insurance. For example, by the Insurance Compensation Consortium, in the most serious and nationally relevant cases.
- Hospitalization for social reasons. That is, if they are patients with functional impairment, who suffer from a chronic disease or pathologies associated with aging and, once the acute phase of the disease is over, they no longer require inpatient health care.
- Health care derived from drug addiction, alcoholism, self-harm, suicide attempt, taking narcotics… In short, in those situations in which the insured has acted negligently and is considered guilty of what happened.
- Voluntary termination of pregnancy. Also assistance at deliveries in private homes or by other alternative means.
- Transplants, except bone marrow and cornea. This is how many companies propose it, although this list may vary, as we will see.
- Surgical interventions of a purely aesthetic nature, which are thus excluded from the benefits offered through the specialty of Reconstructive Plastic Surgery. Nor is Refractive Surgery (for myopia, farsightedness and astigmatism) covered (as a general rule).
- The cost of pharmaceutical products, with the exception of those administered during hospitalization, day hospitalization (as is the case of drugs used in chemotherapy). Nor are medicines not authorized in Spain covered under any circumstances.
What limits condition health insurance coverage?
The fact that a coverage is not included in that list of general exclusions that we have just seen does not mean that it is not also subject to a series of conditions. Because even in situations in which you do have the right to healthcare from your company, the benefits they offer you may include a series of limits and requirements.
The most relevant is the grace period, the time limit that affects the provision of some guarantees such as hospitalization of all kinds, assistance in childbirth, access to high-tech diagnostic means, special treatments and psychotherapy sessions, among other. On the other hand, you will have primary and specialist medical care, emergency care and access to simple means of diagnosis, among other benefits.
Limits on health insurance coverage can also be financial in nature. On the one hand, an economic limit is established in the coverage of expenses covered in certain benefits, such as medical, hospital, surgical and pharmaceutical expenses abroad contemplated by insurance travel assistance. The insurer agrees to reimburse these expenses, up to an amount that is usually around 12,000 euros. But an economic amount can also be imposed for the use of a service: it is what we call co-payment. As for the reimbursement policies, this is precisely the one affected by the economic limit. In other words, the reimbursement of expenses is guaranteed if they go to centers and physicians outside the company’s medical list up to a certain percentage, which usually ranges between 80% and 90% of the total. Although it also depends on whether the expenses have occurred abroad.
On the other hand, there are coverages with a specific limit of use. For example, psychiatric hospitalization. Typically, a maximum of 50 days is established for hospital admission for this reason (per year and insured). A condition that is added to the cases in which this hospital care is provided and in which it is excluded. Related to the use we find another limit: the number of medical sessions covered and that affect the specialties of Psychotherapy, Podiatry, Physiotherapy and Rehabilitation (whether neurological, cardiac or pelvic floor).
