Merritt Personal Lines Manual: The Most Common Exclusions
LIMITATIONS AND EXCLUSIONS
We will not pay benefits for an expense which results from:
a. intentionally self-inflicted wounds;
b. being intoxicated or under the influence of a narcotic, unless administered on the advice of and in such doses as are prescribed by a physician, except as otherwise provided in the Hospital In-patient Coverage.
Medical insurance is designed primarily to cover accidental injuries and diseases, so no coverage is provided for self-inflicted injury.
Policies frequently exclude coverage for injuries which result from an insured being intoxicated or under the influence of drugs (except prescription drugs administered on the advice of a physician).
c. rest care, convalescent care, or rehabilitation, except as provided by any optional rider attached
A policy that provides hospital benefits will commonly exclude expenses for rest care, convalescent care and rehabilitation, except when optional coverages for these types of care are attached to the policy.
d. the insured person committing or attempting to commit an assault, a felony or being engaged in an illegal occupation
An injury that occurs while a person is committing an assault or felony, or engaged in an illegal occupation, is not covered. This provision is designed to support public policies. There is a high risk of personal harm associated with many illegal activities. The insurance companies do not want to reward illegal activity by reducing the personal consequences. In addition to possible criminal penalties, a person who commits certain acts risks bodily injury and a loss of insurance coverage for that injury.
An example: If an insured person is shot while attempting to hold up a store or transacting a sale of illegal drugs, there would be no medical insurance coverage.
e. injury or sickness covered by Workers' Compensation or Employer's Liability Law
On-the-job injuries and occupational diseases are usually covered by workers compensation laws, so they are not usually covered by private medical insurance. (An exception are so-called "24-hour health" policies, which combine workers' comp medical and standard medical coverage into a single insurance policy. While these combined policies were popular in the 1990s; they became less common in the 2000s.)
f. any act of war, declared or undeclared
Injuries resulting from acts of war are excluded because this is a catastrophic exposure and is generally not insurable under any policy -- health or otherwise.
In the wake of the September 11, 2001 terrorist attacks on New York City and northern Virginia, the issue of what constitutes an "act of war" has become relevant to policyholders. While there are likely to be more legislation and lawsuits around this issue, industry conventions have held that a terrorist attack is not an act of war and, therefore, resulting injuries are covered.
