Health Summary Plan Description
The following exclusions apply to all of the Health
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
- Charges for services of practitioners not recognized
by the Plan for the type of treatment
- 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
- 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
- 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
- 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
- Charges submitted for which you are not financially
- Charges submitted more than 15 months after the
date services are incurred (18 months for hospital
- 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