Exclusions and Limitations Applicable to All Benefits Provided Under the Plan

Pre-Existing Conditions Limitation Specific to Hospitalization and Surgery

General Exclusions and Limitations

Benefits are not provided for injury or sickness of a covered person, which directly or indirectly, wholly or partly from:

• Insurrection, rebellion, participation in a riot, commission of or attempt 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 by any Workers' Compensation Act, Occupational Disease Law or sickness law.
• Operating a motor vehicle under the influence of alcohol as evidence blood alcohol level in excess of the state legal intoxication limit.
• Care or treatment related to intentionally self-inflicted injury or self-inflicted sickness.
• Charges for which there is no legal obligation to pay, or no charge indicated 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 specificaly provided for in the plan, charges for routine physical 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 used for research purposes or practices when not generally recognized as additional medical practices.
• Charges for care, treatment, services or supplies that are not appropriately 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 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 mastectomy is because of malignancy and is performed while 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 surgery except for closed or open reduction of fractures or dislocation of the jaw.
• Unless specifically provided in the plan, charges for treatment of major illness.
• Unless specifically provided in the plan, charges for treatment of alcohol or drug abuse.
• Unless specifically provided in the plan, charges for refractions, eye replacement, or their fitting.
• Hearing aids or their fitting.
• Charges in connection with obesity, weight reduction, or dietetic courses except for morbid obesity or disease etiology.
• Charges for treatment or services for Temporomandibular Joint (TMJ) Syndrome, orofacial, or myofascial syndrome whether medical or  scope.
• Charges for reversal procedures in connection with previous male organ sterilization.
• Charges for services related to educational or vocational testing or
• 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 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, or similar organization or the employee of a clinic contracted any such organization.
• Charges for custodial care.
• Charges for care, treatment, services, supplies or confinements primarily to 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, or transporting of radioactive material, including but not limited to reactors or any weapon of war or explosive device employing nuclear fission or fusion.

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Limitations/Exclusion Specific to Hospitalization and Surgery

Benefits are not provided for injury or sickness of a covered person, which directly or indirectly, wholly or partly from:

• Pre-Existing conditions until covered under the plan for six months. Existing condition is any condition for which you received advice or treatment in the 6 months prior to becoming insured.

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