Section 7 – EXCLUSIONS AND GENERAL LIMITATIONS
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:
- 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.
- 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, unless otherwise required by law.
- Amounts in excess of the calendar year maximum benefit amounts.
- Care, treatment or services that are furnished under any governmental institution or agency, except to the extent that such services are reimbursable to an agency of the federal government 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).
- Services for which payment may be obtained from any local, state or federal government agency, except to the extent prohibited by law.
- 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, or to the extent payment is required pursuant to any collective bargaining agreement or other contract. Refer to the Coordination of Benefits section of this Plan regarding coordination with health plans and insurance policies.
- 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 an intentional criminal act.
- 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.
- 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. This exclusion does not apply, however, to the extent that the condition is received or aggravated in the course of self-employment, if all of the following conditions are met: (a) the self-employment is conducted at the participant or beneficiary’s home; (b) the self-employment earns the participant or beneficiary no more than $5,000 per year; and (c) the condition is not covered under any Worker’s Compensation, occupational disease or injury law or similar legislation.
- 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.
- Expenses for treatment of infertility or for conception, including but not limited to, artificial insemination, in- vitro fertilization, ovum transplants, embryo transfers, the cost of donor semen, surrogate parenting, reversal of voluntarily surgically induced sterilization procedures, and other infertility-related services.
- 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, and insertion or removal of breast implants. 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.
- Charges for gastric bypasses, gastric balloons, stomach stapling, jejunal bypasses, “lap band” surgery, and services of a similar nature. In addition, the Plan excludes charges for all services and associated expenses for obesity or weight control treatment, even if you have other medical conditions related to or caused by obesity or the need for weight control, except for obesity screening and counseling as a preventive care service. Obesity includes morbid or gross obesity.
- Custodial Care, domiciliary care, respite care, private duty nursing, rest cures, or care in a home for the aged or institution of a similar nature, except as specifically provided under the Hospice Care Benefit.
- 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.
- Charges for telephone consultations, cancelled or broken appointments, completion of forms or reports, or expenses for cyber medicine providers, other than consultations provided through Teladoc.
- 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.
- 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.
- Nutritional or dietary supplements or substitutes; non-prescription medications or supplements; 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.
- Services and associated expenses for personal blood storage.
- Expenses for replacement or repair of prosthetic devices or durable medical equipment, unless Medically Necessary due to the Participant’s medical condition.
- Services and associated expenses for or which are incidental to sexual reassignment, inter-sex (transsexual) operations, procedures designed to alter physical characteristics to those of the opposite sex, or any resulting medical complications.
- Services and associated expenses for: (1) weight reduction programs, (2) nutritional counseling, except diabetic nutrition training and healthy diet counseling, (3) megavitamin therapy, (4) baldness or hair removal, (5) hypnotism, (6) biofeedback, (7) stress management, (8) pain control, (9) physical exercise or physical conditioning programs, (10) educational services or treatment for a learning disability, and/or (11) any goal-oriented behavior modification therapy.
- 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.
- Any maternity-related expenses for Dependent children, beyond initial Pregnancy diagnosis.
- 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.
- 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.
- 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. The Plan will also provide benefits for TB diagnostic screening provided it is not
for foreign travel.
- Mental health and/or substance abuse treatment for any of the following: relationship, family, marriage, custody, adoption, academic or other counseling or treatment. In addition, involuntary commitments, police detentions, court ordered therapy, mental health and/or substance abuse treatments required as a condition of employment and other similar arrangements are not covered unless also Medically Necessary.
- Any service not specifically listed in this Plan as a Covered Expense, including but not limited to injectibles. All injectibles and specialty prescription medications must be obtained through the Plan’s prescription benefit manager’s specialty pharmacy.
- 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.
- Naturopathic services or supplies consisting of: (1) herbal supplements, (2) essential oils, (3) over the counter remedies, and (4) any experimental remedies and/or practices.
- Services and associated expenses for non-emergency orthopedic or podiatric surgery, except if provided through BridgeHealth or a Preferred Provider.