Exclusions
Exclusions are services, conditions, or expenses that your health or dental plan does not cover under any circumstances. Every policy contains an exclusion list to define what falls outside the scope of coverage. Common exclusions include cosmetic surgery, over-the-counter medications, experimental treatments, fertility procedures, and any service not deemed medically necessary.
How It Works
An exclusion is policy wording that removes or restricts coverage for specified losses, situations, or causes, defining the edge of what the insurer did not agree to cover. An exclusion is not the same as a deductible or a policy limit: a deductible allocates part of the cost of a covered loss to the insured and a limit caps the insurer's payment when coverage exists, whereas an exclusion removes or narrows the coverage itself. Canadian group health plans commonly exclude charges for services or products that are for cosmetic purposes only, charges that are payable under a provincial or territorial health insurance plan, expenses payable under workers' compensation legislation, and experimental products or treatments without substantial evidence of safety and effectiveness. Plans also exclude expenses for services rendered or prescribed by a person who ordinarily resides in the patient's home or is related to the patient by blood, marriage, or common-law partnership. Provincial health plans set their own statutory exclusions; under Manitoba's Excluded Services Regulation, services for an illness or injury arising out of employment for which workers' compensation indemnity is received are not insured services.
Example:
If a Canadian health and dental plan lists cosmetic procedures as an exclusion, an elective treatment such as teeth whitening or a Botox injection will not be reimbursed even though the dental office performed it, because the service falls outside the plan's covered benefits rather than simply being subject to a deductible or coinsurance.
What to Watch For:
In Canadian practice exclusions are not always absolute, because some risks excluded under standard wording can be bought back through an endorsement, a separate policy, or an optional coverage extension. Exclusions are also a leading cause of claim denials: according to an AMF report cited by the CLHIA, over 60% of critical illness claim denials related to limitations or exclusions, pre-existing conditions, not meeting a definition, and survival or waiting periods.
