Many medical expense policies exclude coverage for services rendered by:

Why C is correct

A common exclusion in medical expense policies is treatment furnished by the insured's immediate family members or persons residing in the same household. The exclusion is designed to prevent abuse, because family members can fabricate or inflate claims more easily, and the professional relationship is not an arm's-length transaction. Most policies, by contrast, do cover care from licensed, participating providers, which is the normal arrangement the policy is designed to pay for. Insurers view treatment rendered by immediate family members as an arrangement where the claimant controls the provider, which creates a moral hazard and makes medical necessity difficult to verify. Consequently, medical expense policies routinely exclude such services while still covering licensed professional providers in the normal course.

Why the other options are wrong

• D) Care from licensed physicians who accept assignment is normally covered, not excluded. Physicians who accept Medicare assignment are ordinary covered providers, and accepting assignment has no bearing on whether an exclusion applies.
• A) Board-certified surgeons provide covered care; specialty credentials do not trigger the family-member exclusion. Board certification is a professional credential, not an exclusion trigger; the exclusion is based on the family relationship between the insured and the provider.
• B) Network providers are the core of managed care coverage; using them is covered, not excluded. Participating network providers are exactly whom the plan expects members to use, so network participation cannot be the basis of an exclusion.

Memory hook

Family treating family = suspicious receipts, so policies say no to care from immediate relatives.