General Limitations and Exclusions
Some health care services are not covered by the Plan. Coverage is not available from the Plan for charges arising from care, supplies, treatment, and/or services:
Incurred directly or indirectly as the result of an abortion except when the life of the mother is endangered by the continued Pregnancy, or the Pregnancy is the result of rape or incest.
Relating directly or indirectly to acupuncture, including acupuncture provided in lieu of anesthetic.
That are solely for and/or applicable to administrative costs of completing claim forms or reports or for providing records wherever allowed by applicable law and/or regulation.
After the Termination Date
That are Incurred by the Participant on or after the date coverage terminates, even if payments have been predetermined for a course of treatment submitted before the termination date, unless otherwise deemed to be covered in accordance with the terms of the Plan or applicable law and/or regulation.
For holistic or homeopathic treatment, naturopathic services, and thermography, including drugs.
For manual or electric breast pumps.
That are charged solely due to the Participant’s having failed to honor an appointment.
Complications of Non-Covered Services
That are required as a result of complications from a service not covered under the Plan, unless expressly stated otherwise.
That are for services, supplies, and/or treatment of any Participant that were Incurred while confined and/or arising from confinement in a prison, jail or other penal institution.
For charges relating to consultative information provided by a physician or pharmacist, including telephone conversations.
That are incurred in connection with the care and/or treatment of Surgical Procedures which are performed for plastic, reconstructive or cosmetic purposes or any other service or supply which are primarily used to improve, alter or enhance appearance, whether or not for psychological or emotional reasons, except to the extent where it is needed for: (a) repair or alleviation of damage resulting from an Accident; (b) because of infection or Illness; (c) because of congenital Disease, developmental condition or anomaly of a covered Dependent Child which has resulted in a functional defect. A treatment will be considered cosmetic for either of the following reasons: (a) its primary purpose is to beautify or (b) there is no documentation of a clinically significant impairment, meaning decrease in function or change in physiology due to Injury, Illness or congenital abnormality. The term “cosmetic services” includes those services which are described in IRS Code Section 213(d)(9).
That do not restore health, unless specifically mentioned otherwise.
That are amounts applied toward satisfaction of Deductibles and expenses that are defined as
the Participant’s responsibility in accordance with the terms of the Plan.
Treatment solely for detoxification or primarily for maintenance care is not considered effective treatment. Detoxification is care aimed primarily at overcoming the effects of a specific drinking or drug episode. Maintenance care consists of the providing of an alcohol-free or drug-free environment.
For expenses related to kidney dialysis beyond the 150% of the Medicare National Fee Schedule of the Physician’s fee reference or the discount allowed by EthiCare Advisors, Inc, whichever is the greater discount to the Participant/Plan.
Education or Training Program
Performed by a Physician or other Provider enrolled in an education or training program when such services are related to the education or training program, except as specifically provided herein.
Any health examination required by any law of a government to secure insurance or professional or other licenses, except as required under applicable federal law.
That exceed Plan limits, set forth herein and including (but not limited to) the Maximum Allowable Charge in the Plan Administrator’s discretion and as determined by the Plan Administrator, in accordance with the Plan terms as set forth by and within this document.
That are Experimental or Investigational.
For eye refractions, eyeglasses, contact lenses, or the vision examination for prescribing or fitting eyeglasses or contact lenses (except for aphakic patients, and soft lenses or sclera shells intended for use in the treatment of Disease or Injury). Vision examinations for prescribing or fitting eyeglasses or contact lenses are covered under the Vision Benefits.
Routine foot care and routine services performed by a licensed podiatrist, such as trimming of toenails and callouses.
That are received outside of the United States if travel is for the purpose of obtaining medical services, unless otherwise approved by the Plan Administrator.
Genetic Counseling or Testing
Care and treatment that is either for genetic counseling or testing, except as otherwise covered under the Preventive Care benefit.
That the Participant obtains, but which is paid, may be paid, is provided or could be provided for at no cost to the Participant through any program or agency, in accordance with the laws or regulations of any government, or where care is provided at government expense, unless there is a legal obligation for the Participant to pay for such treatment or service in the absence of coverage. This Exclusion does not apply when otherwise prohibited by law, including laws applicable to Medicaid and Medicare.
That meet the following requirements:
- That are services furnished to the Participant in any veteran’s Hospital, military Hospital, Institution or facility operated by the United States government or by any State government or any agency or instrumentality of such governments.
- That are services or supplies which can be paid for by any government agency, even if the patient waives his rights to those services or supplies.
This Exclusion does not apply to treatment of non-service related disabilities or for Inpatient care provided in a military or other Federal government Hospital to Dependents of active duty armed service personnel or armed service retirees and their Dependents. This Exclusion does not apply where otherwise prohibited by law.
Related to the use of hypnosis.
Immediate Family Member
That are rendered by a member of the immediate Family Unit or person regularly residing in the same household; whether the relationship is by blood or exists in law.
Impregnation and Infertility Treatment
Following charges related to Impregnation and Infertility Treatment: artificial insemination,fertility Drugs,G.I.F.T. (Gamete Intrafallopian Transfer),impotency Drugs such as ViagraTM, in-vitro fertilization, surrogate mother (unless the surrogate is a Participant, in which case the Preventive Care and/or Pregnancy expenses will be covered in accordance with the Plan provisions), donor eggs, collection or purchase of donor semen (sperm) or oocytes (eggs), and freezing of sperm, oocytes, or embryos, or any type of artificial impregnation procedure, whether or not such procedure is successful.
Incurred by Other Persons
That are expenses actually Incurred by other persons.
Long Term Care
That are related to long term care.
For marijuana or marijuana-derived substances (like THC oil), even if the Participant has a prescription and marijuana is legal in the state where he or she lives.
That are not Medically Necessary and/or arise from services and/or supplies that are not Medically Necessary.
That are related to conditions determined by the Veteran’s Administration to be connected to active service in the military of the United States, except to the extent prohibited or modified by law.
That are for Injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the part of any caregiver, Institution, or Provider, as determined by the Plan Administrator, in its discretion, in light of applicable laws and evidence available to the Plan Administrator.
For nicotine withdrawal programs, facilities, Drugs or supplies, except as specified under Preventive Care.
That are Incurred at a time when no coverage is in force for the applicable Participant and/or Dependent.
No Legal Obligation
That are for services provided to a Participant for which the Provider of a service does not and/or would not customarily render a direct charge, or charges Incurred for which the Participant or Plan has no legal obligation to pay, or for which no charges would be made in the absence of this coverage, including but not limited to charges for services not actually rendered, fees, care, supplies, or services for which a person, company or any other entity except the Participant or the Plan, may be liable for necessitating the fees, care, supplies, or services.
For drugs for use outside of a Hospital or other Inpatient facility that can be purchased over-the-counter and without a Physician’s written prescription. Drugs for which there is a non- prescription equivalent available. This does not apply to the extent the non-prescription drug must be covered under Preventive Care, subject to the Affordable Care Act.
That are not accepted as standard practice by the American Medical Association (AMA), American Dental Association (ADA), or the Food and Drug Administration (FDA).
Not Covered Provider
That are performed by Providers that do not satisfy all the requirements per the Provider definition as defined within this Plan.
Not Specified As Covered
That are not specified as covered under any provision of this Plan.
For nutritional supplements, except as specified under Preventive Care.
Charges for the treatment of Obesity or Morbid Obesity and charges related to weight control, including Surgery (i.e., gastric by-pass and similar Surgical Procedures) and complications incurred as a result of such Surgery for the diagnosis of Obesity, including reversals., except for the diagnosis of Morbid Obesity and only when the treatment meets the Utilization Review Company’s criteria for Medical Necessity.
That are for any condition, Illness, Injury or complication thereof arising out of or in the course of employment, including self-employment, or an activity for wage or profit where workers’ compensation or another form of occupational Injury medical coverage may be available.
For oral surgery or dental treatment, except as specifically provided in the Plan.
Related to donation of a human organ or tissue, except as specifically provided.
For orthopedic shoes, unless they are an integral part of a leg brace and the cost is included in the orthotist’s charge, and other supportive devices for the feet.
For osseous surgery.
Other than Attending Physician
That are other than those certified by a Physician who is attending the Participant as being required for the treatment of Injury or Disease, and performed by an appropriate Provider.
Personal Convenience Items
For equipment that does not meet the definition of Durable Medical Equipment, including air conditioners, humidifiers and exercise equipment, whether or not recommended by a Physician.
Postage, Shipping, Handling Charges, Etc
That are for any postage, shipping or handling charges which may occur in the transmittal of information to the Third Party Administrator; including interest or financing charges.
Pregnancy of a Dependent Child
Incurred by an eligible Dependent Child, including, but not limited to, pre-natal, delivery and post-natal care, treatment of miscarriage and complications due to Pregnancy, unless specifically provided as a covered benefit elsewhere in this Plan. NOTE: Preventive care charges for Pregnancy are covered under the Preventive Care benefit in the Medical Benefits section.
Prior to Coverage
That are rendered or received prior to or after any period of coverage hereunder, except as specifically provided herein.
Prohibited by Law
That are to the extent that payment under this Plan is prohibited by law.
That are required as a result of unreasonable Provider error.
For radial keratotomy or other plastic surgeries on the cornea in lieu of eyeglasses.
Routine Physical Examinations
For routine or periodic physical examinations, related x-ray and laboratory expenses, and nutritional supplements, except as provided in the Summary of Benefits.
That are the result of intentionally self-inflicted Injuries or Illnesses. This exclusion does not apply (a) if the Injury resulted from being the victim of an act of domestic violence, or (b) resulted from a documented medical condition (including both physical and mental health conditions);
Related to a sex change operation.
Sexual Dysfunction Therapy or Surgery
For sexual dysfunctions or inadequacies that do not have
psychological or organic basis.
For sterilization procedure reversal.
Subrogation, Reimbursement, and/or Third Party Responsibility
That are for an Illness, Injury or Sickness not payable by virtue of the Plan’s subrogation, reimbursement, and/or third party responsibility provisions.
Temporomandibular Joint Disorder
Charges for the Diagnosis and treatment of, or in connection with, temporomandibular joint disorders, myofascial pain dysfunction or orthognathic treatment.
For travel, whether or not recommended by a Physician, except as specifically provided herein.
That are not reasonable in nature or in charge (see definition of Maximum Allowable Charge), or are required to treat Illness or Injuries arising from and due to a Provider’s error, wherein such Illness, Injury, infection or complication is not reasonably expected to occur. This Exclusion will apply to expenses directly or indirectly resulting from circumstances that, in the opinion of the Plan Administrator in its sole discretion, gave rise to the expense and are not generally foreseeable or expected amongst professionals practicing the same or similar type(s) of medicine as the treating Provider whose error caused the loss(es).
That Incurred as a result of war or any act of war, whether declared or undeclared, or any act of aggression by any country, including rebellion or riot, when the Participant is a member of the armed forces of any country, or during service by a Participant in the armed forces of any country, or voluntary participation in a riot. This Exclusion does not apply to any Participant who is not a member of the armed forces, and does not apply to victims of any act of war or aggression.
For charges related to customizable wheelchairs.
Charges associated with the purchase of a wig.
With respect to any Injury which is otherwise covered by the Plan, the Plan will not deny benefits otherwise provided for treatment of the Injury if the Injury results from being the victim of an act of domestic violence or a documented medical condition. To the extent consistent with applicable law, this exception will not require this Plan to provide particular benefits other than those provided under the terms of the Plan.