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What are the plan benefits?

Who is eligible?

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When is coverage effective and for how long?

What are the plan limitations and exclusions?


What are the plan limitations and exclusions?

Consult your Certificate of Insurance for complete terms and provisions. If you would like a sample certificate, please go here to request one. Request Assistance

Unless specific exceptions to the following limitations and exclusions are made, no benefits shall be payable under the Policy for any expenses caused by, incurred for, or resulting from:
a. Bodily Injury or Sickness which arises out of or in the course of any occupation, self-employment, sole-proprietorship, partnership or employment for wage or profit, or Bodily Injury or Sickness for which the Insured Person has or had a right to compensation under any Workers’ Compensation or occupational disease law;
b. Services or supplies for which no charge is made, or for which the Insured Person is not required to pay, or which are not documented in the Insured Person’s medical file, or for expenses arising from the treatment of a Bodily Injury or Sickness for which the Insured Person is not under the regular care of a Doctor, or for expenses which are not authorized or prescribed by a Doctor;
c. Pregnancy, except that Complications of Pregnancy shall be considered a Sickness under the Policy;
d. War or any act of war, or participation in a riot, or the commission of an assault or felony; or any Bodily Injury or Sickness that occurs while an Insured Person has been determined to be legally intoxicated or under the influence of alcohol or any narcotic, barbiturate or hallucinatory drug, unless administered under the advice of a Physician and taken in accordance with the prescribed dosage;
e. Cosmetic surgery, including but not limited to: (1) surgery to the upper and lower eyelid; (2) augmentation mammoplasty; (3) reduction mammoplasty; (4) revision of breast surgery for capsular contraction or replacement of prosthesis; (5) repair of diastisis recti; (6) abdominoplasty or panniculectomy; (7) orthognatic surgery; (8) full or partial facial lifts; (9) dermal or chemo abrasion; (10) scar revision; (11) otoplasty; (12) lift, stretch or reduction of abdomen, buttocks, thighs or upper arm; (13) silicone injections to any part of the body; and (14) rhinoplasty; unless such surgery is required for a condition resulting from congenital defects or birth abnormalities or from Bodily Injury, and (except for a newborn child) such Bodily Injury occurred while the Insured Person was insured under the Policy;
f. Elective surgery, treatment, drugs, or devices for sexual dysfunction, birth control or treatment of infertility, including sterilization, reversal of sterilization, penile implant, artificial insemination, in vitro fertilization of an ovum and/or development of an embryo in a laboratory, or use of fertility drugs;
g. Prevention or correction of teeth irregularities and malocclusion of jaws by wire appliances, braces or other mechanical aids, or any other care, repair, removal, replacement or treatment of or to the teeth or any surrounding tissues, except: 1) treatment made necessary by Bodily Injury to Sound and Natural teeth incurred while the Insured Person was insured under the Policy; or 2) for the excision of partial bony or full bony impacted teeth or of a tumor or cyst, or an incision and drainage of an abscess or cyst;
h. Treatment or surgery as the result of temporomandibular joint dysfunction, prognathism, retrognathism, microtrognathism, or any treatment or surgery to reposition the maxilla (upper jaw), mandible (lower jaw), or both maxilla and mandible;
i. Cataracts, Keratotomies or other surgical procedures to correct refractive errors, or examinations for and the cost of eyeglasses, contact lenses or hearing aids;
j. Exogenous or morbid obesity, including but not limited to: 1) weight reduction programs of any type; 2) all surgical procedures for the purpose of or as the result of weight reduction of an Insured; and 3) all surgical procedures for reconstruction, repair or reversal of gastric or jejunioleal bypass as a result thereof;
k. Repair or replacement of artificial limbs or eyes;
l. Inpatient (and Outpatient, under the optional Outpatient Prescription Drug Benefit) prescription drugs which are not directly related to a specific diagnosis, not Medically Necessary or legally obtainable without a written prescription by a Doctor; or any Outpatient drugs (prescription or non-prescription) unless under the optional Outpatient Prescription Drug Benefit; or charges for nonprescription drugs;
m. Expenses incurred for periodic physical examinations which are not directly related to treatment of a Bodily Injury or Sickness, charges for routine well baby care, including Hospital newborn nursery charges, or charges for genetic testing and counseling;
n. Taxes or administrative fees, unless required by applicable law; medical care or treatment to the extent that benefits are paid by Medicare or any other governmental law or program (except Medicaid) or by any automobile insurance, or services furnished by a Hospital or institution which: 1) does not meet the definition specified in the Policy; 2) is owned or operated by the United States Government or any agency thereof or is owned or operated by any State, Province or any other political subdivision unless there is a legal obligation for the Insured Person to pay in the absence of insurance;
o. Expenses for treatment, paring or removal of corns, calluses or toenails (other than partial or complete removal of nail roots) except when prescribed by a Doctor who is treating the Insured Person for a metabolic disease, such as diabetes mellitus or peripheralvascular disease such as arteriosclerosis; or treatment of the feet, including strained or flat feet, or instability or imbalance, by posting or strapping, range of motion studies, orthotics, osteotomies, hallux valgus repair, or orthopedic or corrective shoes, or other supportive devices;
p. Expenses incurred as the result of attempted suicide or intentionally self-inflicted Bodily Injury or Sickness while sane or insane;
q. Services received or supplies purchased outside the United States, its territories or possessions or Canada; or travel, transportation or living expenses;
r. Services or supplies which are not Medically Necessary (including experimental or investigative treatment), charges in excess of the Maximum Allowable Charge, or expenses incurred on a date on which the Insured Person is not insured under the Policy;
s. Custodial or Convalescence Care;
t. An organ or tissue transplant or replacement, including the implant of an artificial organ or transplantation of animal or artificial organs or tissues (or any service or supply in connection with the implant or transplantation, including ventricular assist devices), except those organ or tissue transplants or replacements specified under “Eligible Expense”;
u. Any organ which is sold rather than donated to the Insured Person and any service or supply in connection with identification of a donor from a local, state or national listing;
v. Any service or supply in connection with autologous bone marrow transplantation for treatment of any disease other than acute lymphocytic leukemia, acute non-lymphocytic leukemia, Hodgkin’s disease, non-Hodgkin’s lymphoma, neuroblastomas and breast cancer when combined with high dose chemotherapy; or any service or supply in connection with autotransfusion/transplantation of autologous stem cells for the treatment of leukopenia from any cause;
w. Any services or supplies in connection with cigarette smoking cessation; or services related to narcotic maintenance for opiate addiction;
x. A Pre-Existing Condition;
y. Hypnotherapy when used to treat conditions that are not recognized as Nervous, Mental or Emotional Disorder by the American Psychiatric Association; biofeedback; or non-medical self-care or self-help programs;
z. Consultations and/or treatment provided over the Internet;
aa. A hernia, hysterectomy, or treatment or removal of tonsils, adenoids, or gall bladder, except in an Emergency;
bb. Treatment, medication or hormones to stimulate growth, or treatment of learning disorders, disabilities, developmental delays or deficiencies, including therapy;
cc. Sclerotherapy for veins of the extremities;
dd. Kidney or end stage renal disease;
ee. Injuries sustained while participating in any form of sky diving, scuba diving, auto racing, bungee jumping, hang or ultra light gliding, parasailing, sail planing, flying in an aircraft (other than as a passenger on a commercial airline), rodeo contests or as a result of participating in any professional, semi-professional or other non-recreational sports including boating, motorcycling, skiing, riding all-terrain vehicles or dirt-bikes, snowmobiling or go-carting;
ff. Complications of any treatment or surgery for an excluded service or procedure;
gg. Private duty nursing, standby physician charges or medical care, treatment, services or supplies provided by an Insured Person’s Family member;
hh. Joint replacement or other treatment of joints, spine, bones or connective tissue including tendons, ligaments and cartilage, unless due to Bodily Injury incurred while the Insured Person was insured under the Policy;
ii. Chronic fatigue or pain disorders; Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or related immunodeficiency disorders; or
jj. treatment or diagnosis of allergies, except for emergency treatment of allergic reactions.

See Certificate of Insurance for complete details. This is a only a limited description of the Plan. Exact provisions of the plan are contained in the Policy issued to the policyholder. Some provisions, benefits, exclusions & limitations mary vary depending on your state of residence.