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Understanding the Restrictive Clause of Health Insurance

Understanding the Restrictive Clause of Health Insurance

New patients frequently ask me about whether health insurance plans cover naturopathic care or not. The general rule is that they do not. Most health insurance companies around the country view naturopathy as an alternative form of medicine that has not proven effective enough to warrant coverage. My colleagues and I vehemently disagree, but that is another topic for another blog post. What I want to cover today is what is known as the ‘restrictive clause’ found in a typical health insurance policy and how it relates to state insurance regulations.

The restrictive clause is important in the healthcare setting because it partially determines the extent and limitations of coverage. I will explain that in more detail further on in this post. But let us start with defining the terms that will guide the remainder of this discussion.

Definition of a Restrictive Clause

The best way to define a restrictive clause in the healthcare insurance setting is to start by defining what is known as an ‘insuring clause’. According to Dictionary.com’s definition based on the Random House Dictionary, an insuring clause for healthcare purposes is:

“the clause in an insurance policy setting forth the kind and degree of coverage granted by the insurer.”

If an insuring clause establishes the extent to which coverage will be offered to a patient, a restrictive clause establishes the degree to which coverage will be restricted. Though the two kinds of clauses may seem to be just different perspectives of the same topic, their subtle differences make a big difference in legal terms. The state of Arizona provides a good example.

Naturopathic Medicine in Arizona

In an article profiling a patient of naturopathy in Prescott, Arizona the Daily Courier’s Max Efrein explained that the state of Arizona recognizes naturopathic practitioners as qualified primary care providers. As such, insurance companies providing standard primary care coverage to their Arizona customers would, by default, also cover naturopathy. For a health insurer to deny coverage would require a restrictive clause inasmuch as existing insuring clauses already dictate that naturopathy would be covered.

Efrein mentions Blue Cross Blue Shield of Arizona as one insurance company with policies containing a specific restrictive clause excluding coverage for naturopathic care. Patients covered under one of their policies could scan their documents and find this clause quite easily. But what about other patients in Arizona with different coverage?

If a policy’s insuring clause or clauses indicate standard coverage for primary care provided by qualified doctors in Arizona, they would have to provide insurance coverage for naturopathy in the absence of a specific restrictive clause.

The point of explaining this is to help you understand that health insurance differs from one state to the next. Those of us who practice naturopathy can safely say that the vast majority of health insurance providers across America do not cover naturopathic care. But it is certainly not true of all of them.

As a patient, you need to know what the health insurance regulations are in your state before looking at your own policy. Who knows? If the state laws where you live are favorable, you may benefit from the lack of a specific restrictive clause to disqualify naturopathic care from your insurance coverage. So take a look at your policy and the laws in your state. You will not know if you are covered until you do.

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