In addition to any exclusions and limitations described elsewhere
in this Booklet, the following Exclusions and General Limitations
are applicable to all benefits provided under this Plan. These
exclusions shall not be interpreted to violate 26 U.S. Code Section
9802, 29 U.S. Code Section 1182, or 42 U.S. Code Section 300gg-2.
No Plan Benefits are extended for any of the following:
1. Any service rendered or supplies furnished prior to a Participant’s
date of eligibility or after a Participant’s eligibility for coverage
terminates (including treatment for an Illness or Injury arising
prior to the termination of eligibility). An expense is considered
incurred on the date the Participant receives the service for
which the charge is made. For more information, refer to the ELIGIBILITY
RULES section of this Booklet.
2. Care, treatment or services for which there is no legal obligation
of the Participant to pay, or for which no charge is made in the
absence of eligibility for Plan benefits.
3. Amounts in excess of: (1) the $50,000 lifetime maximum applicable
to treatment of substance abuse, or (2) amounts in excess of the
Lifetime Maximum Benefit.
4. Care, treatment or services that are furnished under any governmental
institution or agency, except to the extent that such services
are reimbursable to the Veterans Administration for a non-military
service related Illness or Injury, or must be reimbursed under
the Indian Health Care Act, 25 USC § 1621e(a) and (c).
5. Services for which payment may be obtained from any local,
state or federal government agency.
6. Expenses incurred for which benefits are provided under any
other group insurance policy, other medical benefits or service
plan, union welfare plan or employee benefit plan for which an
employer directly or indirectly makes contributions or payroll
deductions. Refer to the Coordination of Benefits Section of this
Plan.
7. Expenses due to or as a result of: (1) war, act of war, armed
invasion or aggression (declared or undeclared) or service in
the armed forces of any country, or (2) non-therapeutic release
of nuclear energy, or (3) a Participant committing or attempting
to commit a felony, or engaging in the commission of a crime.
8. Any charge for services furnished by any provider not meeting
the definition of Physician or Health Care Provider, or charges
for services by a Relative of the Participant or a member of the
Participant’s household.
9. Expenses relating to any condition for which coverage is
available, if proper claim were made, from Workers’ Compensation,
occupational disease or injury law or similar legislation. The
Plan covers no expenses for any condition arising out of or received
or aggravated in the course of engaging in any activity for wage
or profit.
10. Any expense incurred for: (1) services that are not Medically
Necessary, (2) Experimental and/or Investigational treatment,
(3) fees in excess of Usual, Customary and Reasonable charges,
(4) fees from PPO providers in excess of Preferred Provider rates,
or (5) any services or supplies not considered legal in the U.S.
11. Expenses for treatment of infertility or for conception,
including but not limited to, artificial insemination, invitro
fertilization, ovum transplants, embryo transfers, the cost of
donor semen, surrogate parenting, reversal of voluntarily surgically
induced sterilization procedures, and other infertility-related
services.
12. Services and associated expenses for cosmetic procedures,
including but not limited to pharmacological regimens, nutritional
procedures or treatments, non-Medically Necessary plastic and/or
reconstructive surgery. Cosmetic procedures are those that may
improve physical appearance but do not correct or materially improve
a physiological function and are not Medically Necessary. However,
this Plan will cover surgery related to mastectomy as required
by federal law.
Covered Expenses include cosmetic surgery that is Medically Necessary
for prompt repair of damage caused by Injury sustained before
or while the Participant is covered by the Plan. “Prompt repair”
means that surgery is performed before the end of the calendar
year following the year in which the Injury occurred, except in
situations where repair must be postponed for Medically Necessary
reasons.
13. Services and associated expenses for procedures intended
primarily for treatment of obesity, including gastric bypasses,
gastric balloons, stomach stapling, jejunal bypasses, wiring of
the jaw, and health services of a similar nature. The reference
to obesity herein includes morbid or gross obesity.
14. Custodial Care, domiciliary care, respite care, private duty
nursing, rest cures, or care in a home for the aged 27 or institution
of a similar nature, except as specifically provided under the
Hospice Care Benefit.
15. Charges for personal convenience items such as telephone,
television, guest meals, or similar services and supplies while
confined in a Hospital or Skilled Nursing Facility or while receiving
outpatient care.
16. Charges for telephone consultations, cancelled or broken
appointments, completion of forms or reports, or expenses for
cyber medicine providers.
17. Hospital emergency room care that is not related to an Emergency
and/or could have been provided in a Physician’s office, an outpatient
clinic or urgent care center.
18. Expenses for any surgical procedures which alter the refractive
character of the eye, or any complications as a result of those
surgical procedures. Routine eye examinations, glasses or contact
lenses, or vision therapy including orthoptics, except as specifically
provided under Vision Care Benefits.
19. Nutritional or dietary supplements or substitutes; non-prescription
medications or supplements; and enteral feedings and electrolyte
supplements; except that the Plan will provide benefits for a
fiber supplement where the patient suffers from a diagnosed condition
of elevated cholesterol, and a Physician specifically recommends
the fiber supplement as an alternative to prescription drug treatment
for elevated cholesterol.
20. Services and associated expenses for personal blood storage.
21. Expenses for replacement or repair of prosthetic devices
or durable medical equipment, unless Medically Necessary due to
the Participant’s medical condition.
22. Services and associated expenses for or which are incidental
to sexual reassignment, inter-sex (trans-sexual) operations, procedures
designed to alter physical characteristics to those of the opposite
sex, or any resulting medical complications.
23. Services and associated expenses for: (1) weight reduction
programs, (2) acupuncture, (3) nutritional counseling, except
diabetic nutrition training, (4) megavitamin therapy, (5) smoking
cessation programs, (6) baldness or hair removal, (7) hypnotism,
(8) biofeedback, (9) stress management, (10) pain control, (11)
physical exercise or physical conditioning programs, (12) educational
services or treatment for a learning disability, and/or (13) any
goal-oriented behavior modification therapy.
24. Appliances or equipment primarily for convenience or environmental
control, such as air conditioners, humidifiers and dehumidifiers,
air filters, whirlpools, Jacuzzi or hot tub devices, or exercise
equipment. Expenses incurred for modifications to your home, property,
or vehicles.
25. Any maternity-related expenses for Dependent children, beyond
initial Pregnancy diagnosis.
26. Salabrasion, chemosurgery or other such skin abrasion procedures
associated with the removal of scars, tattoos, actinic changes
and/or performed as a treatment for acne.
27. Services and associated expenses related to care or treatment
for sexual deviations and disorders, attention deficit and other
conduct and impulse disorders with or without hyperactivity (except
Prescription Drugs and Physician Visits are not excluded), autism,
developmental disabilities, vocational disabilities, dyslexia,
learning disorders, and mental retardation or other organic-based
disorders.
28. Examinations or testing when such services relate to or are
performed: (1) in order to obtain insurance, (2) for travel, marriage
or adoption, (3) for judicial or administrative proceedings or
orders, (4) for purposes of medical research, or (5) to obtain
or maintain a license or official document of any type. Notwithstanding
this exclusion, the Plan will provide benefits for ICC, DOT, and
FAA physicals pursuant to the Preventive Health Care provision.
29. Mental health and/or substance abuse treatment for any of
the following: • Relationship, family, marriage, custody, adoption,
academic or other counseling or treatment when not attributable
to Mental Illness. • Involuntary commitments, police detentions,
court ordered therapy, and other similar arrangements unless also
Medically Necessary.
30. Any service not specifically listed in this Plan as a Covered
Expense.
31. Any service related to treatment of injuries or illnesses
caused by the performance of any service or procedure for which
no benefits are extended under the Plan, including, but not limited
to, exclusions 11, 12, 13, 18, 22, 25, 26, and 27
