Can a health plan exclude benefits for treatment of an injury resulting from a medical condition?


Your group health plan generally provides medical/surgical benefits, including benefits for hospital stays, that are medically necessary. However, the plan excludes benefits for self-inflicted injuries or injuries sustained in connection with attempted suicide. Because of depression, one of your employees attempted suicide. The employee sustained injuries and was hospitalized for treatment of the injuries. Under the exclusion, the plan denied the employee benefits for treatment of the injuries. Is this permissible under HIPAA’s nondiscrimination rules?


No. The suicide attempt is the result of a medical condition (depression). Accordingly, the denial of benefits for the treatment of the employee’s injuries violates HIPAA’s rule relating to source-of-injury exclusions because the plan provision excludes benefits for treatment of an injury resulting from a medical condition.

If a group health plan or group health insurance coverage generally provides benefits for a type of injury, the plan or issuer may not deny benefits otherwise provided for treatment of the injury if the injury results from an act of domestic violence or a medical condition (including both physical and mental health conditions). This rule applies in the case of an injury resulting from a medical condition even if the condition is not diagnosed before the injury.

Source: HHS Reg. Sec. 146.121(b)(2)(iii), Example 1.

[ Return to top of document ]