Subject to any rights under the law, including the right to appeal a denial of benefits, we have the authority to interpret and apply the terms of the Contract and to determine whether and to what extent you have coverage for a requested service, even when a Provider has prescribed or recom-mended this service.
We pay benefits only for Covered services and supplies described in your Contract. Your Certificate and any of its Riders or Endorsements may contain specific exclusions.
In addition to the specific exclusions listed elsewhere in your Contract, the following General Exclusions apply:
Services or supplies that must be Covered by a prior health plan as extended benefits.
Services or supplies for which you would have no legal obligation to pay if you did not have your Contract or similar coverage.
Services or supplies for which there is no charge.
Services or supplies paid for directly or indirectly by a local, state or federal government agency, except as otherwise provided by law.
Services or supplies you require as a result of your commission or attempt to commit a felony, or your engagement in an illegal occupation.
Services or supplies in excess of the limitations or maximums set forth in your Contract.
Services or supplies we determine are not Medically Necessary.
Services, supplies or medications that we determine are Investigational, mainly for research purposes or Experimental in nature.
Services or supplies that are not provided in accordance with accepted professional medical standards in the United States.
Acupuncture, acupressure or massage therapy; hypnotherapy, rolfing, homeopathic remedies or naturopathic remedies.
Alpha Stim® Units.
Automatic ambulatory home blood pressure monitoring.
Biofeedback or other forms of self-care or self-help training.
Whole blood, blood components, costs associated with the storage of blood, testing of blood the patient donates for his or her own use (even if the blood is used), transfusion services for blood and blood components the patient donates for his or her own use in the absence of a covered surgical procedure. (This exclusion does not apply to blood derivatives and transfusion services for whole blood, blood components and blood derivatives.)
Care for which there is no therapeutic benefit or likelihood of improvement.
Care, the duration of which is based upon a predetermined length of time rather than the condition of the patient, the results of treatment or the individual’s medical progress.
Clinical ecology, environmental medicine, Inpatient confinement for environmental change or similar treatment.
Cognitive training or retraining and educational programs, including any program designed principally to improve academic performance, reading or writing skills, except for diabetes education.
Screening colonoscopies except in patients over age 50 or patients with risk factors for colorectal disorders.
Communication devices, communication augmentation devices and computer technology or accessories and other equipment, supplies or treatment intended primarily to enhance occupational, recreational or vocational activities, hobbies or academic performance.
Consultations except when they occur between Providers and the Providers attach a written report to the patient’s medical record.
Correction of near- or farsighted conditions or aphakia (where the lens of the eye is missing congenitally, accidentally or has been surgically removed, as with cataracts) by means of corneal microsurgery or “laser Surgery,” such as keratomileusis, keratophakia, and radial keratotomy and all related services.
Cosmetic procedures and supplies that are not Reconstructive.
Custodial Care or rest cures.
Dental care, services and supplies and oral Surgery, unless specifically provided by your Contract; procedures designed primarily to prepare the mouth for dentures (including alveolar augmentation, bone grafting, frame implants and ramus mandibular stapling).
Eye exercises or visual training.
Eyeglasses or contact lenses unless you need them to replace the lens of the eye (and the lens wasn’t replaced at the time of the surgery).
Education, educational evaluation or therapy or treatment of developmental delays, except for treatment of diabetes such as medical nutrition therapy by approved Network Providers.
Foot care or supplies that are Palliative or Cosmetic in nature, including supportive devices and treatment for bunions (except capsular or bone Surgery), flat-foot conditions, subluxations of the foot, corns, callouses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet. This exclusion does not apply to necessary foot care for people with diabetes.
Hearing aids or examinations for the prescription or fitting of hearing aids.
Home or automobile modifications or equipment such as air conditioners, HEPA filters, humidifiers, stair glides, elevators, lifts, motorized scooters, furniture or “barrier-free” construction, even if prescribed by a Provider.
Illnesses or injuries which are:
a result of an act of war (declared or undeclared); or
sustained in active military service (Note: upon receipt of written request, the Plan will suspend coverage for the military member and make a refund on a pro rata basis for subscription rates paid for the time period the member is in active military service).
An Inpatient Stay determined not Medically Necessary while you are waiting for a different level of care, such as Skilled Nursing Facility or home care, whether or not it is available to you.
Institutional or Custodial Care for the physically or mentally handicapped.
Treatment for willfully uncooperative or intractable patients.
Mandated treatment, including court-ordered treatment, unless such treatment is Medically Necessary, ordered by a Physician and Covered under your Contract.
Nonmedical charges, such as:
a penalty for failure to keep a scheduled visit; or
fees for completion of a claim form.
Neuromuscular stimulators unless you have Prior Approval from us.
Nutritional counseling beyond three visits per calendar year. (This exclusion does not apply to nutritional counseling for treatment of diabetes.)
Nutritional formulae or supplements, except for up to $2,500 per year for “medical foods” prescribed for the Medically Necessary treatment of an inherited metabolic disease or formulae or supplements administered through a feeding tube.
Orthodontics, including orthodontics performed as adjunct to orthognathic surgery or in connection with accidental injury.
Pain management programs.
Personal hygiene items.
Personal service or comfort items.
Photography services, photographic supplies or film development supplies or services (for example, external ocular photography or photography of moles to monitor changes).
Physical fitness equipment, braces and devices intended primarily for use with sports or physical activities other than activities of daily living (e.g. knee braces for skiing, running or hiking); weight loss or exercise programs; health club or fitness center memberships.
Specialized examinations required by your employer or for sports/recreational activities (e.g. driver certifications, pilot flight physicals, etc.)
Services or supplies that should be covered in a Child’s Individualized Education Plan (IEP) or other educational program.
Support therapies, including pastoral counseling, assertiveness training, dream therapy, music or art therapy, recreational therapy, smoking cessation therapy, stress management, wilderness programs, adventure therapy and bright light therapy.
More than one attempt at reversal of sterilization.
Telephone consultations (between Provider and patient).
TENS (transcutaneous electrical nerve stimulation) units, except with written Prior Approval from us. (Note: We will not approve a TENS unit to treat headache, pelvic or deep abdominal pain or jaw pain.)
Therapy services provided as a part of chronic pain control, developmental, pulmonary or other form of rehabilitation, except:
treatment of diabetes by a Network Provider; or
upon prior written approval by the Plan.
Travel (other than ambulance transport) or lodging, even if prescribed by a Physician.
Treatment solely to establish or reestablish the capability to perform occupational, hobby, sport or leisure activities.
Evaluation and treatment, including medications, leading to, or in connection with, artificial insemination (intravaginal, intracervical, and intrauterine insemination), in vitro fertilization, embryo transplantation and gamete intrafallopian transfer (GIFT). This exclusion does not apply to the evaluation to determine if and why the couple is infertile.
Treatment leading to, or in connection with, transsexual Surgery.
Non-prescription treatment of obesity, except surgical treatment when:
your Physician determines that your Body Mass Index is over 40 (according to Table 1 in the “Methods for Voluntary Weight Loss and Control” booklet by the National Institute of Health Technology Assessment Conference Statement of March 1992); and
you have other medical conditions that could be significantly and adversely affected by this degree of obesity.
Work-related illnesses or injuries (or those which you claim to be work-related, until otherwise finally adjudicated), provided such illnesses or injuries are covered by workers’ compensation or should be so covered (This provision shall not be deemed to require, as a condition to obtaining coverage, an individual, such as a sole proprietor or owner partners, to obtain workers’ compensation if he or she is not under legal obligation to be so covered.)
Services and supplies not specifically described as Covered.
Also, your Contract does not Cover services or supplies prescribed or provided by a:
Provider we do not approve for the given service or that is not defined in our “Definitions” section as a Provider.
Professional who provides services as part of his or her education or training program.
Member of your immediate family or yourself.
Veterans Administration Facility treating a service-connected disability.
Nonparticipating Provider, if we require Participation as a condition for coverage under your Contract.
Non-Network Provider, if we require Network participation as a condition for coverage under your Contract.