Participating Provider Plan does not provide benefits for:
- Any amounts in excess of maximum amounts of Covered Expenses stated in this Plan.
- Services not specifically listed in this Plan as Covered Services.
- Services or supplies that are not Medically Necessary as defined by the Insurer.
- Services or supplies that the Insurer considers to be Experimental or Investigative.
- Services received before the Effective Date of coverage or during an inpatient stay that began before that Effective Date of Coverage.
- Services received after coverage ends unless an extension of benefits applies as specifically stated under Extension of Benefits in the 'Who is Eligible for Coverage' section of this Plan.
- Services for which the Insured Person has no legal obligation to pay or for which no charge would be made if he/she did not have a health policy or insurance coverage.
- Services for any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or occupational disease law, even if the Insured Person does not claim those benefits.
- Conditions caused by or contributed by: (a) An act of war; (b) The inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) An Insured Person participating in the military service of any country; (d) An Insured Person participating in an insurrection, rebellion, or riot; (e) Services received for any condition caused by an Insured Person's commission of, or attempt to commit a felony or to which a contributing cause was the Insured Person being engaged in an illegal occupation; (f) An Insured Person, age 19 or older, being under the influence of illegal narcotics or non-prescribed controlled substances unless administered on the advice of a Physician.
- Any services provided by a local, state or federal government agency except when payment under this Plan is expressly required by federal or state law.
- Professional services received or supplies purchased from the Insured Person, a person who lives in the Insured Person's home or who is related to the Insured Person by blood, marriage or adoption, or the Insured Person's employer.
- Inpatient or outpatient services of a private duty nurse.
- Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
- Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
- Treatment of Mental, Emotional of Functional Nervous Disorders (including nicotine use) or psychological testing except as specifically stated in this Plan. However, medical conditions that are caused by behavior of the Insured Person and that may be associated with these mental conditions are not subject to these limitations.
- Treatment of Drug, alcohol, or other substance addiction or abuse, except as specifically stated in this Plan.
- Dental services, dentures, bridges, crowns, caps or other dental prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically stated under Dental Care for an Accidental Injury in the Benefits section of this Plan.
- Dental and orthodontic services for Temporomandibular Joint Dysfunction.
- Orthodontic Services, braces and other orthodontic appliances.
- Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated procedure as part of the implantation or removal of dental implants.
- Hearing aids.
- Routine hearing tests except as provided under Preventive and Primary Care.
- Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Plan.
- An eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), astigmatism and/or farsightedness (presbyopia).
- Outpatient speech therapy.
- Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Plan. This includes, but is not limited to, items dispensed by a Physician.
- Any intentionally self-inflicted Injury or Illness. This exclusion does not apply to the Medical Evacuation Benefit, to the Repatriation of Remains Benefit and to the Bedside Visit Benefit.
- Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical community. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a newborn child, or to Medically Necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
- Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
- Treatment of sexual dysfunction or inadequacy.
- All services related to the evaluation or treatment of fertility and/or Infertility, including, but not limited to, all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures including sterilization reversals and In vitro fertilization, except as specifically stated under Benefits, What the Plan Pays For Sterilization.
- All contraceptive services and supplies, including but not limited to, all consultations, examinations, evaluations, medications, medical, laboratory, devices, or surgical procedures unless stated otherwise.
- Cryopreservation of sperm or eggs.
- Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
- Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method of treatment.
- Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority except as specifically stated under the Professional and other Services and Preventive and Primary Care sections of this Plan.
- Charges by a provider for telephone consultations.
- Items which are furnished primarily for the Eligible Participant's personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, etc.).
- Educational services except as specifically provided or arranged by the Insurer.
- Nutritional counseling or food supplements.
- Durable medical equipment not specifically listed as Covered Services in the Covered Services or Infusion Therapy sections of this Plan. Excluded durable medical equipment includes, but is not limited to: orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings.
- Any services received on or within 6 months after the Effective Date of coverage if they are related to a Pre-existing Condition as defined in the Definitions section.
- Physical and/or Occupational Therapy/Medicine, except when provided during an inpatient Hospital confinement or as specifically provided under the benefits for Physical and/or Occupational Therapy/Medicine.
- All Infusion Therapy together with any associated supplies, Drugs or professional services are excluded except as specifically provided under the benefit for Infusion Therapy described in this Plan.
- Growth Hormone Treatment.
- Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet.
- Charges for which the Insurer is unable to determine the Insurer's liability because the Eligible Participant or an Insured Person failed, within 60 days, or as soon as reasonably possible to (a) authorize the Insurer to receive all the medical records and information the Insurer requested or, (b) provide the Insurer with information the Insurer requested regarding the circumstances of the claim or other insurance coverage.
- Charges for the services of a standby Physician.
- Charges for animal to human organ transplants.
Benefits are not available for any services received: (1) on or within 6 months after the Eligibility Date of an Insured Person who is not a Late Enrollee; or (2) on or within 6 months after the Effective Date of Coverage for a Late Enrollee, if those services are related to a Pre-existing Condition as defined in the Definitions section. This exclusion does not apply to a Newborn that is enrolled within 31 days of birth or a newly adopted child that is enrolled within 31 days from either the date of placement of the child in the home, or the date of the final decree of adoption.
The Insurer will credit time an Insured Person was covered by Creditable Coverage that was in effect up to a date not more than 63 days before the Effective Date of Coverage under this Plan, excluding the Waiting Period.
This limitation does not apply to the Medical Evacuation Benefit, the Repatriation of Remains Benefit and to the Bedside Visit Benefit.