Health insurance: Coverage, exclusions and benefits.

Health insurance: Coverage, exclusions and benefits.

Is it worth hiring health insurance? According to each individual's needs, the answer will always be affirmative. But then, what does it cover, what does it exclude, and what are the advantages of subscribing to this insurance?

11 Aug 20235 min

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What does health insurance cover?

Health insurance aims to cover risks associated with providing healthcare, through the coverage that a client includes.

Coverage can be triggered either through a reimbursement system to the policyholder who incurs health care expenses or through a direct payment by the insurer for health services. There may also be a combination of both systems.

But, after all, what does a health insurance cover? The most common coverage of a health insurance includes:

  • Outpatient (consultations, treatments);
  • Accident outpatient clinic;
  • Hospitalization (admission, surgical interventions)  
  • Stomatology (dental medicine consultations or maxillofacial, orthodontics, prostheses);
  • Birth (hospitalization, birth, medication, transportation);
  • Serious illnesses (in this case, hospitalization and outpatient capital are reinforced);
  • Patient follow-up (after discharge from hospital);
  • Inclusion in provider network (can access a network of conventional medical services in the country);
  • Inclusion in a well-being network (areas such as osteopathy, psychology, acupuncture);
  • Online inquiries;
  • Doctor at home;
  • Second medical opinion;
  • Death by accident coverage.

What excludes health insurance?

You must know that if the client receives a contribution from a Social Security system, health insurance will only cover the expenses that are not subsidized.

In addition, there are also coverages excluded from health insurance, which you should pay attention to if you are one of those you intend to include with your contracting.

According to the Insurance and Pension Funds Supervisory Authority, the following coverages are excluded from health insurance: .

  • Occupational diseases and work-related accidents;
  • Nervous disorders and psychiatric diseases;
  • Check-up and general health exams;
  • Disturbances caused by alcohol or drug abuse;
  • Accidents or illnesses resulting from participation in sports competitions;
  • Treatment or surgery for weight loss;
  • Fertilization or methods of artificial insemination;
  • Organ or bone marrow transplant;
  • Treatment or aesthetic, plastic, or reconstructive surgery and its consequences (except if necessary due to a disease or accident covered by insurance);
  • Stays in psychiatric institutions, thermal baths, rest homes, nursing homes, detox centers for alcohol or drug addicts.

Regarding pre-existing conditions, if they are known to the policyholder at the time of signing the contract, they are covered (unless expressly excluded in the contract).

And it is also worth noting that the contract may indicate a waiting period, not exceeding one year, regarding coverage of pre-existing conditions.

How do payment systems work in health insurance?

As mentioned, there are different payment systems in health insurance: the reimbursement system and the direct payment system by the insurer to service providers included in the network, with a possible combination of both.

In the reimbursement system, expenses are paid directly by the policyholder, with the insurance company reimbursing the amount later on.

To understand the value to be refunded, you must know that, in the contract, it is established:

  • What are the maximum co-financing percentages;
  • The amount available for each coverage;
  • The value of the initial franchise fee for each coverage (if any);
  • The deadline to submit the expenses refund request is based on the date they were incurred; this URL provides more information.
  • The maximum deadline for the insurer to reimburse the policyholder.

In the direct payment system, when making health care expenses, the policyholder only pays the part that is not covered by insurance, if the service provider is included in the conventional network. The portion covered by the insurer is paid directly to the service provider.

What are the advantages of hiring health insurance?

The advantages of hiring health insurance are related to the ease of access to healthcare, without waiting times and with a greater choice of options. In case of accidents or illnesses, it is possible to act more easily, preventing more serious scenarios.

In addition to reducing wait times for access, and having a broader choice of options, health insurance also ensures greater specialization in counseling. By guaranteeing a wide network of service providers, you have access to all specialties and then some. This leads to greater peace of mind and protection when in need of specific care.

Having health insurance is a freedom, as you know you can have access to all necessary care in a personalized way.

If you want to take out health insurance, in order to make the right decision and more suitable for you and your family, you can turn to the services of an insurance mediator like those at Poupança no Minuto. At no cost, they help you choose the most suitable insurance on the market, comparing proposals and answering all your questions.


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