General Exclusions & Limitations

Benefits are not provided for Loss, Injury or Illness of a Covered Person which results directly or indirectly, wholly or partly from:

• Insurrection, rebellion, participation in a riot, commission of or attempting to commit an assault, battery, felony, or act of aggression.
• Declared or undeclared war or acts thereof.
• Accidental Bodily Injury occurring while serving on full-time active duty in any Armed Forces of any country or international authority (any premium paid will be returned by Us pro-rata for any period of active-full time duty).
• Any Injury or Illness arising out of or in the course of work for wage or profit.
• Any Injury or Illness paid by any Worker's Compensation Act, Occupational Disease Law or similar law.
• Except in regard to Medical benefits, bodily injuries received while the Covered Person was operating a motor vehicle under the influence of alcohol as evidenced by a blood alcohol level in excess of the state legal intoxication limit.
• Charges for which: (1) there is no legal obligation to pay, or (2) no charge is made, or (3) 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. This does not apply to Medicaid or where prohibited by law.
• Charges which are not Medically Necessary (as defined) for treatment of Illness or Injury.
• Charges for services which are not related to and consistent with the treatment of any Injury or Illness of the Covered Person.
• Unless specifically provided in the Plan, charges for routine physicals or general health exams, unless they are necessary for the diagnosis and treatment of an Illness.
• Charges for medical care, services, or supplies which are not furnished or prescribed by a Doctor (as defined).
• Charges for experimental or investigational treatment, procedures for research purposes, or practices when not generally recognized as accepted medical practices.
• Charges for care, treatment, services or supplies that are not approved or accepted as essential to the treatment of an Injury or Illness by any of the following:
  1. The American Medical Association;
  2. The U.S. Surgeon General;
  3. The U.S. Department of Public Health;
  4. The National Institute of Health; or
  5. The professional review organization(s) which administer the Utilization Review Program.
• Charges related to cosmetic surgery or Dental Care done to beautify a person without medical or dental indication of Injury or Illness. This exclusion does not apply to charges related to treatment of congenital defects of a newborn child.
• Unless specifically provided in the Plan, charges for:
  1. Dental treatment;
  2. Oral Surgery.
• Unless specifically provided in the Plan, charges for treatment of Mental Illness Disorders.
• Unless specifically provided in the Plan, charges for treatment of Substance Abuse Disorders.
• Unless specifically provided in the Plan, charges for refractions, eyeglasses or hearing aids or their fitting.
• Unless specifically provided in the Plan, charges in connection with obesity, weight reduction, or dietetic control, except for morbid obesity or disease etiology.
• Unless specifically provided in the Plan, charges for treatment or services for temporomandibular joint dysfunction or TMJ pain syndrome, orofacial, or myofascial syndrome whether medical or dental in scope.
• Charges for reversal procedures in connection with previous male or female sterilization.
• Unless specifically provided in the Plan, charges for routine immunizations and vaccinations, including but not limited to polio, mumps, measles, small pox, DPT, or tine tests.
• Charges for services in the nature of educational or vocational testing or training.
• Any charges for elective abortions.
• Any charges for outpatient food, food supplements or vitamins.
• Radial keratotomies
• Any charges in excess of the Plan maximums for Organ or Tissue Transplants as shown in the Summary of Benefits.
• 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:
  1. Drugs and medicines;
  2. 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 for stand-by surgeons, pediatricians, anesthesiologists, anesthetists, or other Doctor as defined by the Plan; or stand-by supplies, equipment, rooms, or any other service, supply or treatment not actually used in the care or treatment of an Illness or Injury.
• Charges made by; durable medical equipment recommended by; or drugs dispensed by; a physician, surgeon, nurse or other Doctor (as defined) who:
  1. Normally lives with the Insured; or,
  2. Is a member of the Insured's family; or
  3. Is the Insured's Policyholder.
• Charges for Custodial Care.
• Charges related to smoking cessation.
• Charges for the treatment of the following:
  1. Codependency;
  2. Social, occupational, or religious maladjustments;
  3. Compulsive gambling;
  4. Chronic marital or family problems when not related to the primary focus of treatment which must be a diagnosable mental disorder.