Health Benefits Advisor for Employers

Determining Compliance with the HIPAA Provisions in Part 7 of ERISA

Compliance with HIPAA Nondiscrimination Provisions - Source of Injury Restrictions

If the plan imposes a source-of-injury restriction, does it comply with the HIPAA nondiscrimination provisions?

• Yes
• No
• Not Applicable

Plans may exclude benefits for the treatment of certain injuries based on the source of that injury, except that plans may not exclude benefits otherwise provided for treatment of an injury if the injury results from an act of domestic violence or a medical condition. See 29 CFR 2590.702(b)(2)(iii). An example of a permissible source-of-injury exclusion would include:

• A plan provision that provides benefits for head injuries generally, but excludes benefits for head injuries sustained while participating in bungee jumping, as long as the injuries do not result from a medical condition or domestic violence.

An impermissible source-of-injury exclusion would include:

• A plan provision that generally provides coverage for medical/surgical benefits, including hospital stays that are medically necessary, but excludes benefits for self-inflicted injuries or attempted suicide. This is impermissible because the plan provision excludes benefits for treatment of injuries that may result from a medical condition (depression).