HomeMy WebLinkAboutRESPONSE - RFP - P682 BENEFITS (12)SECTION 2 - BENEFIT EXCLUSIONS AND LIMITATIONS
A. THE FOLLOWING EXCLUSIONS AND LIMITATIONS APPLY TO ALL BENEFITS:
1. All services for a surrogate mother who is not an Insured Individual are not covered
2. Any accidental bodily injury which arises out of or in the course of any employment with any employer, including
self-employed individuals, or for which the individual is entitled to benefits under any worker's compensation law or
occupational disease law, or receives any settlement from a worker's compensation carrier, unless it is shown in the
Schedule of Benefits that the insurance provided by a benefit is issued on both an occupational and non -occupational
basis.
3. Any illness for which the individual is entitled to benefits under any worker's compensation or occupational disease
law, or receives any settlement from a worker's compensation carrier.
4. Charges due to a pre-existing illness or condition, except as shown in the Schedule of Benefits.
5. Charges due to tissue transplants, organ transplants or replacement of tissue or organs, whether natural or artificial
replacement materials or devices are used; and all charges due to complications arising from such procedures or
treatment unless such charges are specifically provided for on the Schedule of Benefits.
6. Charges for any treatment for cosmetic purposes or for cosmetic surgery, including aging of the skin, hair loss, or
excess hair. Except for cosmetic treatment or surgery:
a. due solely to an accidental bodily injury which occurred while the individual was insured under this Policy; or
b. for the reconstructive surgery and prosthetic devices following mastectomy for breast cancer;
c. due solely to a birth defect of an individual who was insured under this Policy on the date of his or her birth.
7. Charges for cognitive therapy, by any name called.
8. Charges for custodial, domiciliary, convalescent, and/or intermediate care, including rest cures (collectively "custodial
care"), whether furnished in the home or in an institution, including a nursing home or similar facility. See the definition
of "custodial care" in the Definition Section, Section 7.
9. Charges for dental services or supplies for treatment of the teeth, gums or alveolar processes. Except for hospital
charges if the Insured Individual is a bed patient and the admission is necessary for a medical reason as authorized
and pre -certified and except for any dental charges covered under the Major Medical.
10. Charges for diagnosis or treatment of temporomandibular joint dysfunction, by any name called. EXCEPT, this
limitation does not apply to such charges which result in payments not exceeding a total of $1,000.00 while insured,
subject to the Deductible and benefit percentage shown on the Schedule of Benefits.
11. Charges for donor semen for artificial insemination, in vitro fertilization, in vivo fertilization, embryo transport
procedures, surrogate parenting, injectable substances, medications used to correct physiological abnormalities or to
stimulate the individual's natural reproductive system, supplies, procedures and all other associated expenses related
to infertility.
12. Charges for eye glasses or contact lenses or the fitting of them, if Vision Benefits are not included in this policy. Except
as specified under Major Medical Benefits for cataract surgery.