General Exclusions and Limitations
Benefits are not provided for injury or sickness of a covered person, which results directly or indirectly, wholly or partly from: - Insurrection, rebellion, participation in a riot, commission of or attempting to commit an assault, battery, felony, or act of aggression.
- War or any act of war, whether declared or undeclared, or sickness contracted or accidental bodily injury occurring while on full-time active duty in the Armed Forces of any country or combination of countries.
- Occupational injury or sickness or any injury or sickness otherwise covered by any Workers' Compensation Act, Occupational Disease Law or similar law.
- Operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state legal intoxication limit.
- Care or treatment related to intentionally self-inflicted injury or self-induced sickness.
- Charges for which there is no legal obligation to pay, or no charge is made, or in the absence of coverage no charge would be made.
- Charges incurred after termination of coverage.
- Charges for care or services furnished by any agency or program funded by federal, state or local government except Medicaid.
- Charges which are not medically necessary for treatment of sickness or injury.
- Unless specifically provided for in the plan, charges for routine physicals or exams or routine immunizations when no injury or sickness is present.
- Charges for medical care, services, or supplies, which are not furnished or prescribed by a doctor.
- Charges for experimental or investigational treatment, procedures for research purposes or practices when not generally recognized as accepted medical practices.
- Charges for care, treatment, services or supplies that are not approved or accepted as essential to the treatment of an injury or sickness by any of the following:
- The American Medical Association;
- The U.S. Surgeon General;
- The U.S. Department of Public Health;
- The National Institute of Health.
- Charges related to cosmetic surgery except:
- To repair disfigurement because of an accidental bodily injury which occurs while covered under the plan; and
- For reconstructive surgery because of mastectomy which is performed within 12 months of the date of a mastectomy, provided that the mastectomy is because of malignancy and is performed while covered under the plan; and
- For treatment of a congenital anomaly in a child born to the insured while covered under the plan.
- Unless dental care benefits are included in the plan, dental care or oral surgery except for closed or open reduction of fractures or dislocation of the jaw.
- Unless specifically provided in the plan, charges for treatment of mental illness.
- Unless specifically provided in the plan, charges for treatment of alcohol or drug abuse.
- Unless specifically provided in the plan, charges for refractions, eyeglasses or their fitting.
- Hearing aids or their fitting.
- Charges in connection with obesity, weight reduction, or dietetic control, except for morbid obesity or disease etiology.
- Charges for treatment or services for Temporomandibular Joint (TMJ) Syndrome, orofacial, or myofascial syndrome whether medical or dental in scope.
- Charges for reversal procedures in connection with previous male or female sterilization.
- Charges for services related to educational or vocational testing or training.
- Any charges for abortions, which are not medically necessary.
- Any charges for outpatient food, food supplements, or vitamins.
- Any charges for prescription drugs or durable medical equipment.
- Surgery to correct vision problems, which are not caused by a sickness or injury.
- Charges for treatment of male or female infertility; in vitro and in vivo fertilization of an ovum; or artificial insemination including but not limited to:
- Drugs and medicines;
- Diagnostic and surgical procedures including but not limited to:
- Aspiration of ovarian cysts;
- Harvesting or obtaining eggs;
- Other surgical treatment of infertility;
- Diagnostic laboratory and pathology procedures; and
- Diagnostic radiology, nuclear medicine and ultra sound procedures
- Charges made by a surgeon, nurse, dentist or doctor who:
- Normally lives with the covered person;
- Is a member of the covered person's family; or
- Is the covered person's Sponsor or another employee of the Sponsor; or
- Is contracted for or by a union, employee benefit association, trustee, or similar organization or the employee of a clinic contracted for or by any such organization.
- Charges for custodial care.
- Charges for care, treatment, services, supplies or confinements primarily for the convenience of the covered person, his doctor, his family or other providers.
- Charges related to smoking cessation.
- Treatment received outside of the United States except for emergency treatment while traveling.
- The processing of nuclear fission or fusion, or the processing, use, handling or transporting of radioactive material, including but not limited to nuclear reactors or any weapon of war or explosive device employing nuclear fission or fusion.
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Pre-Existing Conditions Limitation Specific to Hospitalization and Surgery
Benefits are not provided for injury or sickness of a covered person, which results directly or indirectly, wholly or partly from:- Pre-Existing conditions until covered under the plan for six months. A pre-existing condition is any condition for which you received advice or treatment in the 6 months prior to becoming insured.
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Exclusions Specific to the Dental Care Benefits of the Plan
Benefits are not provided for any charges or expenses incurred by a covered person which result directly or indirectly, wholly or partly from:- Replacement of a tooth extracted prior to the covered person’s effective date;
- Dentures, crowns, inlays, onlays, bridgework or appliances or services for increasing vertical dimensions;
- Denture or bridgework adjustments;
- Replacement of a lost or stolen prosthesis or for a duplicate prosthesis;
- Oral hygiene, diet or plague control instructions and programs;
- Athletic mouth guards;
- Temporary denture or bridge;
- Failure to appear as scheduled for an appointment;
- Tooth re-implantology not resulting from an accident;
- Drugs except for injectable antibiotics administered by a dentist;
- Procedures, services, or supplies, which do not meet accepted standards of dental practice;
- Treatment initiated prior to coverage under the plan, except for comprehensive orthodontic treatment as defined by the policy; or
- Expenses which are not specifically listed in the Schedule of Benefits.
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