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Benefits and Exemptions
This is a brief summary of Legion Limited Medical Plan. Benefits are subject to the policy limitations and exclusions. Refer to the policy, certificate, and riders for complete details.
|Inpatient Daily||$500 per day x 30 days|
|ICU (5 days)||$500 per day x 5 days|
|Inpatient Surgery||$500 per day x 2 days|
|Office Visits||$100 per day x 3 days|
|Wellness Visit Benefits||$50 per day x 1 day|
|Wellness Visit Baby Benefits||$50 per day x 1 day|
|ER Sickness||$100 per day x 2 days|
|Outpatient Surgery||$500 per day x 1 day|
|Diagnostic, X-ray and Laboratory|
|Class 1: Laboratory-Blood work, CMP, Lipid Panel, ECG, Pap/PSA, urinalysis and all other laboratory tests|
Maximum number of days for laboratory tests including blood work, comprehensive metabolic panel, lipid panel, all other lab per Plan Year
|$50 per day x 2 days|
|Class II: Radiology, Ultrasound, Mammogram, Sonogram, Angiogram||$50 per day x 2 days|
|Class III: Imaging CT, PET||None|
|Class IV: Other Diagnostic tests- Endoscopy, Bronchoscopy, Colonoscopy without Biopsy, MRI||$50 per day x 1 days|
Exclusions and Limitations
Benefits in connection with a Pre-existing Conditions occurring within the first twelve (12) months of coverage are not payable. “Pre-existing Condition” means an illness, disease, or other condition of the Covered Person, that was treated, diagnosed or required medications in the six (6) month period before the Covered Person’s coverage became effective under this Policy. This Pre-Existing Condition Limitation shall not apply after the end of the Limitation Period shown in the Schedule of Benefits, commencing on the Insured Person’s Coverage Effective Date.
In addition to any benefit or coverage specific exclusion, benefits will not be paid for any loss which directly or indirectly, in whole or in part, is caused by or results from any of the following unless coverage is specifically provided for by name in the Description of Benefits section of the insurance certificate:
- Intentionally self-inflicted injury, suicide or any attempt while sane or insane;
- ILLEGAL OCCUPATION: The insurer shall not be liable for any loss to which a contributing cause was the insured’s commission of or attempt to commit a felony or to which a contributing cause was the insured’s being engaged in an illegal occupation.
- Declared or undeclared war or act of war;
- Release, whether or not accidental, or by any person unlawfully or intentionally, of nuclear energy or radiation, including sickness or disease resulting from such release;
- An injury or sickness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, the Company will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;
- Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency;
- Flight in, boarding or alighting from an Aircraft except as: a fare-paying passenger on a regularly scheduled commercial or charter airline; a passenger in a non-scheduled, private Aircraft used for pleasure purposes with no commercial intent during the flight;
- Travel in any Aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An Aircraft will be deemed to be “controlled” by the Policyholder if the Aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year;
- Bungee-cord jumping, parachuting, skydiving, parasailing, hang-gliding;
- Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage;
- The Insured Person’s intoxication. The Insured Person is conclusively deemed to be intoxicated if the level in his blood exceeds the amount at which a person is presumed, under the law of the locale in which the accident occurred, to be under the influence of alcohol if operating a motor vehicle, regardless of whether he is in fact operating a motor vehicle, when the injury occurs. An autopsy report from a licensed medical examiner, law enforcement officer’s report, or similar items will be considered proof of the Insured Person’s intoxication;
- An Accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) the Insured Person holds a valid learners permit and (b) the Insured Person is receiving instruction from a driver’s education instructor;
- Alcoholism, drug addiction or the use of any illegal drug or narcotic except as prescribed by a Physician unless specifically provided herein;
- Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration;
- Repair, replacement, examinations for prescriptions or the fitting of eyeglasses or contact lenses.
- Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed.
- Mental and nervous disorders.
- Elective surgery or cosmetic surgery, except for reconstructive surgery needed as the result of a Covered Injury or Covered Sickness.
- Experimental or Investigational drugs, services, supplies. For the purposes of this exclusion, “Experimental or Investigational” means medical services, supplies or treatments provided or performed in a special setting for research purposes, under a treatment protocol or as part of a clinical trial (Phase I, II or III). The covered service will also be considered Experimental or Investigational if the Insured Person is required to sign a consent form that indicates the proposed treatment or procedure is part of a scientific study or medical research to determine its effectiveness or safety. Medical treatment, that is not considered standard treatment by the majority of the medical community or by Medicare, Medicaid or any other government financed programs or the National Cancer Institute regarding malignancies, will be considered Experimental or investigational. A drug, device or biological product is considered Experimental or Investigational if it does not have FDA approval or approval under an interim step in the FDA process, i.e., an investigational device exemption or an investigational new drug exemption.
- Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.
- Sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery.
- Services related to sterilization, reversal of a vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a Covered Injury or Covered Sickness.
- Treatment or services provided by a private duty nurse.
- Organ or tissue transplants and related services.
- Personal comfort or convenience items.
- Rest or custodial cures.
- Hearing aids.
- An Injury or Sickness for which the Insured Person is paid benefits under any Workers’ Compensation or occupational disease law or under any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident.
In addition, benefits will not be paid for services or treatment rendered by any person who is:
- Employed or retained by the Policyholder;
- Living in the Insured Person’s household;
- An Immediate Family Member of either the Insured Person or the Insured Person’s Spouse;
- The Insured Person.