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Here is What Your Health Insurance Does Not Cover and Why It is Just as Important

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Jennifer Lawrence
Here is What Your Health Insurance Does Not Cover and Why It is Just as Important

Health insurance is a type of insurance coverage offered by health insurance companies in Sri Lanka that helps individuals and families pay for medical expenses and healthcare services. It functions as a contract between the insured person (the policyholder) and the insurance company, where the policyholder pays regular premiums, and in return, the insurer agrees to cover a portion of the medical costs when the need arises. Many companies offer similar policies under employee insurance plans that help their staff members be covered in case of illness or hospitalization.


The purpose of these policies is to provide financial protection against the high costs of medical treatments, hospitalization, prescription drugs, and other healthcare services. It can be obtained through various sources, including employers, government programs, private insurance companies, or healthcare exchanges.


Key points about health insurance:

  • Premiums: Policyholders pay regular premiums, usually on a monthly basis, to maintain their coverage. Premium amounts may vary depending on factors such as the type of plan, the policyholder's age, location, and family size.
  • Deductibles: A deductible is the amount that the policyholder must pay out of pocket for covered medical services before the insurance company starts contributing. After reaching the deductible, the insurer usually covers a percentage of the remaining costs.
  • Co-payments and Coinsurance: Co-payments are fixed, upfront costs that the policyholder must pay for certain services, such as doctor visits or prescription medications. Coinsurance, on the other hand, is a percentage of the cost of a covered service that the policyholder must pay after meeting the deductible.
  • Network: These types of plans often have a network of healthcare providers (doctors, hospitals, clinics, etc.) with whom they have negotiated discounted rates. Using in-network providers usually results in lower out-of-pocket expenses for the insured.
  • Out-of-Network: If a policyholder seeks care from a healthcare provider outside the insurance company's network, they may have to pay higher costs or, in some cases, the entire cost of the service themselves.
  • Covered Services: They typically cover a range of medical services, including preventive care, hospitalization, emergency care, prescription drugs, and sometimes mental health services and maternity care. However, the specific coverage details can vary significantly depending on the policy and insurance provider.


It is essential to carefully review and understand the terms and coverage of a health insurance policy before getting the best medical insurance in Sri Lanka for your needs. Having such a policy can offer financial security and access to medical care, which can be crucial in times of illness or medical emergencies.


Here is what your health insurance may not cover and why they are just as important


Health insurance does not cover certain services, treatments, or expenses, and understanding these exclusions is crucial to avoid unexpected financial burdens. Some common examples of services that these policies may not cover include:

  • Cosmetic Procedures: It typically does not cover elective cosmetic surgeries or procedures performed solely for aesthetic purposes, as they are considered non-essential and not medically necessary.
  • Experimental or Investigational Treatments: Treatments that are still in the experimental or investigational stages and have not been proven effective or approved by regulatory authorities may not be covered by health insurance.
  • Certain Alternative Therapies: It may not cover certain alternative or complementary therapies, such as acupuncture or naturopathy unless explicitly included in the policy.
  • Long-Term Care: It usually does not cover long-term care in nursing homes or assisted living facilities, as these services are more related to custodial care than medical treatment.
  • Infertility Treatments: Many plans do not cover fertility treatments, including in vitro fertilization (IVF) and related procedures.
  • Dental and Vision Care: In many cases, standard health insurance does not cover routine dental check-ups, dental procedures, or vision care. Separate dental and vision insurance policies are typically required for coverage in these areas.
  • Pre-existing Conditions: Some plans may impose waiting periods or exclusions for pre-existing conditions. These are medical conditions that the insured had before obtaining the health insurance policy.
  • Over-the-counter medications: Most policies do not cover the cost of over-the-counter medications without a prescription.


The reasons for these exclusions vary, but some common factors include cost considerations, the desire to keep premiums affordable, and the focus on covering treatments and services that are considered essential for maintaining health and treating illnesses. Including coverage for some of these services could significantly increase the cost of insurance for everyone, making it less accessible to many individuals and families.


It is important to note that while health insurance may not cover certain services or treatments, there are often alternative ways to access these services or financial assistance programs available. Additionally, specific coverage details can vary between plans and providers, so it is essential to carefully review the policy terms and ask questions to understand what is and is not covered before choosing a plan. For services that are not covered, individuals may consider exploring supplemental plans or health savings accounts (HSAs) to help manage potential out-of-pocket expenses.


How to cover the costs for things not covered in a health insurance plan?


If there are medical services or treatments that are not covered by your health insurance plan, there are several options to explore to obtain coverage or assistance for those expenses:


  • Supplemental Insurance: Consider purchasing supplemental plans that are designed to complement your primary coverage. These plans may provide additional benefits for specific services, such as dental, vision, critical illness, or accident coverage.
  • Riders or Add-ons: Some policies offer optional riders or add-ons that can be purchased to extend coverage for specific services not covered in the standard policy. For example, you may be able to add a maternity rider or coverage for certain alternative therapies.
  • Discount Programs: Look into discount programs that may be available for services not covered by insurance. Some providers offer discounted rates for certain medical procedures or treatments, which can help reduce out-of-pocket expenses.
  • Health Savings Account (HSA): If you have a high-deductible plan, you may be eligible to open a Health Savings Account (HSA). HSAs allow you to set aside pre-tax money to pay for qualified medical expenses, including some services that may not be covered by your insurance.
  • Negotiate with Providers: In some cases, you may be able to negotiate with healthcare providers for lower rates or payment plans for services that are not covered by insurance. Many providers are willing to work with patients to find affordable solutions.
  • Non-profit Organizations and Charities: There are charitable organizations and non-profits that offer financial assistance or support for specific medical conditions or treatments. Research if there are any organizations that could help with your particular needs.
  • Government Assistance Programs: Depending on your income and circumstances, you may qualify for government assistance programs that provide coverage for certain medical services. Examples include Medicaid (for low-income individuals and families) and state-specific programs.
  • Medical Tourism: In some cases, individuals may choose to travel to other countries for certain medical treatments or procedures that are more affordable there. However, it is essential to carefully research and consider the risks and quality of care when exploring this option.
  • Personal Savings: Building an emergency fund or setting aside money for medical expenses not covered by insurance can be a proactive way to prepare for unexpected healthcare costs.


Remember to thoroughly research and understand the terms and conditions of any additional coverage options or assistance programs you consider. It is also a good idea to discuss your options with a qualified insurance advisor or financial professional to make informed decisions based on your specific needs and circumstances.

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