Faculty & Staff

Benefit’s Limitations and Exclusions

This plan will NOT pay for:

  1. Charges exceeding reasonable and customary, as determined by the Claim Administrator.
  2. Expenses not related to a condition of illness or injury.
  3. Expenses related to a non-covered service.
  4. Expenses not specifically included within this Plan Description as benefits of the Plan.
  5. Hospital charges or related physician fees during inpatient admissions primarily for care which could be performed safely on an out-patient basis.
  6. Non-surgical in-patient hospital admission for back pain.
  7. Hospital or facility charges for out-patient surgery for a vasectomy or for the removal of benign moles/nevi/lesions or for other services which are performed normally on an out-patient basis in a physician’s office.
  8. Non-accident use of a hospital emergency room in the absence of a condition which would result in permanent medical consequences in the absence of immediate medical attention.
  9. Hospital admissions commencing or other services received before an individual’s effective date of coverage in the Plan, or after termination from the Plan. If covered by another group health care plan, coverage for existing in-patient admissions also will terminate at the time your coverage terminates under this Plan.
  10. Personal comfort items such as television rental, barber services, special meals or guest meals.
  11. Routine physical exams, school medical exams, physicals for athletics, immunizations, and vaccinations except as provided as stated elsewhere on this site.
  12. Charges for a nurse/nurse practitioner except when under the direction of an MD.
  13. Charges for a physician’s assistant except when under the direction of an MD.
  14. Job-related injuries or diseases covered by or pending under Workers Compensation or similar legislation, or for which a final decision has not been made by the Worker’s Compensation Commission on a claim that has been filed under Worker’s Compensation.
  15. Expenses in federal or state institutions except tax- supported regional mental health centers, or general acute care university hospitals.
  16. Expenses payable by Medicare, or which would have been payable by Medicare had the person properly enrolled in Medicare or applied for Social Security Disability benefits in order to qualify for Medicare in the event the person is disabled (does not apply where contrary to federal law). Disabled individuals must apply for Social Security Disability benefits the later of 9/1/2004 or within six (6) months after the date of disability.
  17. Expenses in connection with custodial care, education or training, or for which you or the patient are not liable for payment in the absence of health care plan coverage.
  18. Injury or illness due to war or act of war or while serving in the armed forces.
  19. Cosmetic surgery unless necessary to correct traumatic injuries incurred while covered under the Plan or the program it replaced or to correct any congenital deformities evidenced in infancy.
  20. Expenses related to: mastectomy in the absence of a malignancy or expenses related to breast reduction or enlargement other than post-mastectomy reconstructive surgery following a covered mastectomy; dependent daughter pregnancy; sex changes; penile implants; infertility; growth hormone therapy; artificial insemination; or reverse sterilization procedures. (Sterilization procedures performed after at least one full year of eligible employment are covered).
  21. Hearing aids and the tests for the fitting thereof, or other charges for services performed by an audiologist beyond the maximum benefit of the Plan.
  22. Routine foot care such as trimming nails and callouses.
  23. Expenses related to bariatric surgery or weight reduction or expenses related to nutrition counseling or nicotine addiction.
  24. Expenses related to radial keratotomy or other surgical procedures to correct nearsightedness, farsightedness or similar conditions.
  25. Orthotics
  26. Mandibular or maxillary (jaw) surgery except for fracture repair
  27. Treatment for temporomandibular joint dysfunction (TMJ)
  28. Vision care expenses not included under Vision Care Benefits unless related to cataract surgery or non-refractive diseases of the eye
  29. The “facility fee” billed by a physician’s office or licensed surgery center when the provider does not have an agreement with the Plan or the claim administrator
  30. Telephone calls
  31. Customized wheelchairs
  32. Travel expenses
  33. Expenses denied by another health care plan or HMO for lack of pre-treatment approval, improper claim filing procedures or lack of additional physician opinions
  34. Services which do not meet accepted medical standards or are considered investigational, experimental, or not medically necessary under Medicare criteria
  35. Expenses covered by auto, property and casualty or liability insurance or for which another party or organization is liable for payment. Upon completion of the Plan’s reimbursement agreement, these expenses may be paid at the option of the Claim Administrator on an interim basis while the settlement with such other insurance, party or organization is pending.
  36. Expenses related to kidney dialysis beyond 150% of the Medicare National Fee Schedule of the Physician’s fee Reference.
  37. Inpatient substance abuse charges beyond the PPO prices of White Oaks Center for adults and Chestnut Health System for adolescents