What are the basics of health insurance coverage?

Health insurance contracts are frequently group insurance contracts wherein you, as a member of a group, pay a premium to the insurance company in return for the insurance company agreeing to cover medical and hospital expenses up to certain limits. The general limitation of the scope of coverage under these policies is that the treatment that you receive must be reasonable and nec­essary and the cost of the treatment must be consistent with the usual and customary charges for other practitioners in the area.

For instance, if you decide to have plastic surgery that is pure­ly elective, this type of treatment may not be covered unless you have a specific endorsement or provision within your policy that provides coverage since the treatment is not necessary. Likewise, if you choose to go to the most expensive orthopedic surgeon in the area because you think he or she is the best, all of the charges rendered by that surgeon may not be covered under your policy. The policy is governed by what is usual and customary for those types of services and not necessarily by what the best practitioner in that area may charge.

Because of the complexity of health insurance policies, you may not have a clear understanding of what is covered and to what extent it is covered. This can be a real problem when most need the insurance and assume that you will be covered.

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