General Exclusions And Limitations

The Plan does not provide coverage for the following items:

1. Care, supplies, or equipment not Medically Necessary, as determined by the Plan, for the treatment of an Injury or illness. The determination whether care, supplies or equipment are Medically Necessary shall be made by the Trustees, or their designee, in their absolute discretion and in accordance with the provisions of Section 19 of the Plan Document.

2. Services rendered or supplies provided before coverage begins, i.e., before a Participant's Effective Date, or after coverage ends. Such services and supplies shall include, but not be limited to Inpatient Hospital admissions which begin before a Participant's Effective Date, continue after the Participant's Effective Date, and are covered by a prior carrier.

3. Any services rendered or supplies provided while you are confined in a facility which does not meet the definition of "hospital" as set forth at Section 1.12 of this Plan Document.

4. Any services rendered or supplies provided while you are a patient or receive services at or from a person or entity which does not meet the definition of "health care provider" set forth at Section 1.11 of this Plan Document.

5. Any portion of a provider's fee or charge which is ordinarily due from a Participant, but which has been waived. If a provider routinely waives (does not require the Participant to pay) a Deductible or an Out-of-Pocket amount, the Claims Administrator will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived.

6. Care for any condition or Injury recognized or allowed as a compensable loss through any Workers' Compensation, occupational disease or similar law.

7. Any disease or Injury resulting from a war, declared or not, or any military duty or any release of nuclear energy. Also excluded are charges for services directly related to military service provided or available from the Veterans' Administration or military medical facilities as required by law.

8. Any item, service, supply or care not specifically listed as a Covered Service in this Plan Document.

9. Care given by a medical department or clinic run by your Employer.

10. Admission or continued Hospital or Skilled Nursing Facility stay for medical care or diagnostic studies not medically required on an Inpatient basis.

11. Care of corns, bunions (except capsular or related surgery), calluses, toenail (except surgical removal or care rendered as treatment of the diabetic foot or ingrown toenails), flat feet, fallen arches, weak feet, chronic foot strain, or asymptomatic complaints related to the feet.

12. Daily room charges while this Plan is paying for an Intensive Care, cardiac care, or other special care unit.

13. Vision therapy unless needed due to intraocular surgery.

14. Routine physical examinations, screening procedures, and immunizations necessitated by employment, foreign travel or participation in school athletic programs, recreational camps or retreats, which are not called for by known symptoms, illness or injury except those which may be specifically listed herein.

15. The following items related to Durable Medical Equipment are specifically

  • Bed related items: bed trays, over the bed tables, bed wedges, custom bedroom equipment, nonpower mattresses, pillows, posturepedic mattresses, low air mattresses (powered), alternating pressure mattresses;
  • Bath related items: bath lifts, nonportable whirlpool, bathtub rails, toilet rails, raised toilet seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, spas;
  • Chairs, Lifts and Standing Devices: computerized or gyroscopic mobility systems, roll about chairs, geri chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts (mechanical or motorized – manual hydraulic lifts are covered if the patient is two-person transfer), vitrectomy chairs, auto tilt chairs and fixtures to real property (ceiling lifts, wheelchair ramps, automobile lift customizations);
  • Air quality items: room humidifiers, vaporizers, air purifiers, electrostatic machines;
  • Blood/injection related items: blood pressure cuffs, centrifuges, nova pens, needle-less injectors;
  • Pumps: back packs for portable pumps;
  • Dialysis Machines;
  • Other equipment: heat lamps, heating pads, cryounits, ultraviolet cabinets, sheepskin pads and boots, postural drainage board, AC/DC adapters, Enuresis alarms, magnetic equipment, scales (baby and adult), stair gliders, elevators, saunas, exercise equipment, diathermy machines.

16. Custodial Care, domiciliary care, rest cures, or travel expenses even if
recommended for health reasons by a Physician. Inpatient room and board charges in connection with a Hospital or Skilled Nursing Facility stay primarily for environmental change, Physical Therapy or treatment of chronic pain, except as specifically stated as Covered Medical Expenses. Transportation to another area for medical care is excluded except when Medically Necessary for a Participant to be moved by ambulance from one Hospital to another Hospital. Ambulance transportation from the Hospital to the home is not covered.

17. Services provided by a rest home, a home for the aged, a nursing home or any similar facility.

18. Services provided by a Skilled Nursing Facility.

19. Cosmetic Surgery, reconstructive surgery, pharmacological services, nutritional regimens or other services for beautification, or treatment relating to the consequences of, or as a result of, Cosmetic Surgery, unless treatment relating to such consequences is medically necessary. This exclusion includes, but is not limited to, surgery to correct gynecomastia and breast augmentation procedures, and otoplasties. Reduction mammoplasty and services for the correction of asymmetry, except when determined to be medically necessary, are not covered.

• This exclusion does not apply to surgery to restore function if any body area has been altered by disease, trauma, congenital/developmental anomalies, or previous therapeutic processes. This exclusion does not apply to surgery to correct the results of injuries when performed within 2 years of the event causing the impairment, or as a continuation of a staged reconstruction procedure, or congenital defects necessary to restore normal bodily functions, including but not limited to, cleft lip and cleft palate.

• This exclusion does not apply to Breast Reconstructive Surgery.

20. Complications of non-covered procedures are not covered.

21. Any services or supplies for the treatment of obesity, including but not limited to, weight reduction, medical care or Prescription Drugs, nutritional counseling or dietary control. Nutritional supplements; services, supplies and/or nutritional sustenance products (food) related to enteral feeding except when it's the sole means of nutrition. Food supplements. Services of Inpatient treatment of bulimia, anorexia or other eating disorders which consist primarily of behavior modification, diet and weight monitoring and education. Any services or supplies that involve weight reduction as the main method of treatment, including medical or psychiatric care or counseling. Weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature. Procedures including but not limited to liposuction, gastric balloons, jejunal bypasses, and wiring of the jaw.

22. Surgical or medical treatment or study related to the modification of sex (transsexualism) or medical or surgical services or supplies for treatment of sexual dysfunctions or inadequacies, including treatment for impotency (except male organic erectile dysfunction).

23. Transportation provided by other than a state licensed professional ambulance service, and ambulance services other than in a medical emergency.

24. Hair transplants, hair pieces or wigs (except when necessitated by disease), wig maintenance, or prescriptions or medications related to hair growth.

25. Advice or consultation given by any form of telecommunication.

26. Services and supplies for which you have no legal obligation to pay, or for which no charge has been made or would be made if you had no health insurance coverage.

27. Charges for failure to keep a scheduled visit or for completion of claim forms; for Physician or Hospital's stand-by services; for holiday or overtime rates.

28. The following forms of therapy: vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetic therapy, cognitive therapy, electromagnetic therapy, vision perception training (orthoptics), salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or which are performed as a treatment for acne, services and supplies for smoking cessation programs and treatment for nicotine addiction, and carbon dioxide.

29. Radial keratotomy; and surgery, services or supplies for the surgical correction of nearsightedness and/or astigmatism or any other correction of vision due to a refractive problem.

30. Treatment where payment is made by any local, state, or federal government (except Medicaid), or for which payment would be made if the Participant had applied for such benefits. Services that can be provided through a government program for which you as a member of the community are eligible for participation. Such programs include, but are not limited to, school speech and reading programs.

31. Services paid under Medicare or which would have been paid if the Participant had applied for Medicare and claimed Medicare benefits.

32. Those charges in excess of the usual, customary and reasonable amount for the area. A determination as to whether charges are excessive shall be made by the Trustees, or their designee, in their absolute discretion in accordance with the provisions of Section 19 of this Plan.

33. Services related to or performed in conjunction with artificial insemination, in-vitro fertilization or a combination thereof.

34. Biofeedback, recreational, educational or sleep therapy or other forms of self-care or self-help training and any related diagnostic testing.

35. Personal comfort items such as those that are furnished primarily for your personal comfort or convenience, including those services and supplies not directly related to medical care, such as guests' meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, and take-home supplies.

36. Educational services and treatment of behavioral disorders, together with services for remedial education including evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental and learning disorders, behavioral training, and cognitive rehabilitation.

37. Injuries received while committing a crime.

38. Biomicroscopy, field charting or aniseikonic investigation.

39. Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision) or visual training.

40. Non-emergency treatment of chronic illnesses received outside the United States performed without authorization.

41. Any drug or other item which does not require a prescription.

42. Court-ordered services, or those required by court order as a condition of parole or probation.

43. Hypnotherapy.

44. Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.

45. Specific non-standard allergy services and supplies, including but not limited to, skin titration (Rinkle method), cytotoxicity testing (Bryan's Test), treatment of non-specific candida sensitivity, and urine autoinjections.

46. Specific medical reports, including those not directly related to treatment of the Participant, e.g., employment or insurance physicals, and reports prepared in connection with litigation.

47. Thermograms and thermography.

48. Elective abortions.

49. Substance Abuse Treatment.

50. Private Duty Nursing.

51. Injuries incurred as a result of a suicide attempt, or intentionally self-inflicted injury while sane.

52. Custodial Care, domiciliary care, rest cures or travel expenses even if recommended for health reasons by a Physician.

53. Any item, service, supply or care not specifically listed as a covered service in
this Plan.

54. Services or supplies not prescribed or directed by a Physician.

55. Court ordered examinations or care.

56. Stop smoking aids, or services of stop-smoking clinics.

57. Physical therapy to maintain motor functions unless there is a chance of improvement or reversal.

58. Conditions related to hospitalization for environment changes.

59. Services provided by a family member or by a provider's employee to a co-worker.

60. Experimental or investigative procedures.

61. Those charges for examination or tests for check-up purposes which are not incidental to and necessary for the treatment of illness or injury.

62. Charges for cosmetic corrective eye surgery.

63.  Treatment of a Mental Health Disorder.