Health Summary Plan Description

General Exclusions

The following exclusions apply to all of the Health Plan benefits:

Charges for any injury or sickness resulting from or occurring during the commission of, or attempt to commit, a felony.

  • Charges for completing claim forms, reports or copying of medical records.
  • Charges for Experimental or Investigative procedures (see Glossary on page 108).
  • Charges for military related injury or illness. However, any governmental agency has the right to be reimbursed for any charges for services rendered which are not military related.
  • Charges for on-the-job injuries or illnesses. These charges are excluded whether or not your employer obtained a Workers' Compensation policy. Occupational injuries or illnesses are normally covered by Workers' Compensation Insurance. If you work through a loan-out company, you should make sure that your employer covers you under its Workers' Compensation policy. The Plan will consider charges for injuries or illnesses that are specifically excluded from Workers' Compensation laws.
  • Charges for services of practitioners not recognized by the Plan for the type of treatment rendered.
  • Charges for services or supplies not recommended by a doctor.
  • Charges for services or supplies which are provided by any Government or governmental political subdivision in conjunction with the operation of their correctional or mental health programs.
  • Charges for services rendered by providers who are not licensed by the appropriate state or federal authority.
  • Charges for services rendered to you by a provider who is an "immediate relative". An "immediate relative" includes husband and wife, natural or adoptive parent, child and sibling, stepparent, stepchild, stepbrother, and stepsister, father-in-law, mother-in-law, sister-in-law, brother-in-law, son-in-law, daughter-in-law, grandparent and grandchild, spouse of grandparent and grandchild. This exclusion does not apply to benefits provided under the Express Scripts prescription drug program.
  • Charges for state mandated benefits. The Health Plan is self-funded and, therefore, is not subject to state mandated insurance laws because of its exemption provided under ERISA.
  • Charges for telephone, email or internet consultations.
  • Charges in excess of the Contract Allowance (see Glossary on page 107). In addition, network providers cannot bill you for covered charges in excess of the Contract Allowance.
  • Charges in excess of the Plan's Allowance (see Glossary on page 107).
  • Charges in excess of the Reasonable Charge (see Glossary on page 109).
  • Charges incurred for a service or supply that is not Medically Necessary (see Glossary on page 108).
  • Charges incurred on account of declared or undeclared war, and illness or injuries resulting from war, whether declared or undeclared, or any act of war.
  • Charges submitted for which you are not financially responsible.
  • Charges submitted more than 15 months after the date services are incurred (18 months for hospital charges).
  • Charges that are not considered appropriate for the treatment of an illness or accident.
  • Charges for services or supplies that are ordered from internet retailers such as Amazon, Overstock and eBay.