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Benefits5007501000
Hospital Confinement
Daily Hospital Confinement Benefit$500$750$1,000*
Maximum Number of Days per Certificate Year303030
Intensive Care Unit
Daily Hospital Confinement Benefit$0$0$1,100*
Maximum Number of Days per Certificate Year0010
Emergency Room
Daily Emergency Medical Services Benefit$100$100$300
Maximum Number of Days per Certificate Year111
Surgery -- Inpatient Benefits
Daily Inpatient Surgery Benefit$500$750$1,500
Maximum Number of Days per Certificate Year111
Surgery -- Outpatient Benefits
Daily Outpatient Surgery Benefit$500$750$750
Maximum Number of Days per Certificate Year111
Doctor Office Visits
Daily Doctor's Office visit Benefit$50$75$80
Maximum Number of Days per Certificate Year555
Preventative Care Office Visit
Daily Preventive Care office visit Benefit$75$75$75
Maximum Number of Days per Certificate Year111
Diagnostic Advanced Studies
Daily Diagnostic Advanced Studies Benefit$0$0$75
Maximum Number of Days per Certificate Year002
Diagnostic X-Rays
Daily X-Ray test Benefit$50$50$75
Maximum Number of Days per Certificate Year223
Diagnostic Lab Tests
Daily Lab Test Benefit$50$50$75
Maximum Number of Days per Certificate Year223
Ambulance
Daily Ambulance trip Benefit$100$100$100
Maximum Number of Days per Certificate Year333
Maternity Coverage BeneftNoNoNo
30 Day Wait for SicknessNoNoNo

Exclusions

Virtually all health insurance policies have exclusions that are listed in the insurance contract. It is important that a member know those exclusions. Below is a list of some of the more common Health Benefit Insurance exclusions (for a complete listing read your specific insurance contract)

Pre-existing Condition Limitation

Loss caused by or relating to a Pre-existing Condition is not covered for the first 12 months after the certificate effective Date of each covered person.

Pre-existing Condition means a condition not otherwise excluded by name or specific description:

  1. for which medical advice, testing, care, treatment or medication was given or was recommended by, or received from, a physician within 12 months before the Certificate Effective Date; or
  2. that would have caused a reasonable person to seek medical diagnosis or treatment within 12 months before the Certificate effective Date.

Limitations and Exemptions

Any services not specified in the Certificate of Coverage are not covered services under this Group Accident and Sickness Hospital Indemnity Plan.

We will not pay benefits for treatment, services or supplies which:

  • Occur when the coverage is not in force;
  • Are not Medically Necessary;
  • Are not prescribed by a Physician as necessary to treat Sickness or injury, except for the Preventive Care Benefit;
  • Are Experimental/Investigative in nature, except as required by law;
  • Are received without charge or legal obligation to pay, except for Medicaid; or
  • Are provided by Immediate Family.

Additional Limitations and Exclusions:

Except as specifically provided for in this coverage or any attached Riders, We will not pay benefits for death, Sickness or injuries that are caused by:

Dental Procedures – We will not pay benefits for Dental care or treatment except for such care or treatment necessitated by accidental injury to sound natural teeth within 12 months of the accident, and except for dental care or treatment necessary due to congenital disease or anomaly.

Elective Procedures and Cosmetic Surgery – We will not pay benefits for cosmetic surgery, except for reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other disease of the involved part and reconstructive surgery because of congenital disease or anomaly of a covered Dependent Child which has resulted in a functional defect. In the case of a Covered Person who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, We will pay the Surgery Benefit, shown on the Certificate Schedule for:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  • Prostheses and the treatment of physical complications at all stages of mastectomy, including lymphedemas. The maximum benefit paid for breast reconstruction surgery will be defined by the Surgery Benefit in the Certificate Schedule.
  • Felony or Illegal Occupation – We will not pay benefits for death, sickness or injuries incurred during the commission or attempted commission of a felony, or to which a contributing cause was the Named Insured’s being engaged in an illegal occupation.

    Intoxication - We will not pay benefits for death or injuries that are contributed to in whole or in part from: The Covered Person’s being intoxicated (defined as blood alcohol concentration equal to or in excess of the legal limit of the state or jurisdiction in which the injuries occurred). This applies whether or not the Covered Person is charged with any legal violation in connection with a loss; and there is no need to prove a loss was caused, contributed to, or resulted from the excessive blood alcohol concentration; or the covered person’s: 1) voluntary use of illegal drugs; 2) the intentional taking of over the counter medication not in accordance with recommended dosage and warning instructions; or 3) intentional misuse of prescription drugs.

    Pregnancy – We will not pay for medical treatment related to Pregnancy and childbirth except for those services required to treat Complications of Pregnancy, as defined in the Definitions section of this Certificate.

    Suicide or Injuries Which Any Covered Person Intentionally Does to Him/Herself – We will not pay benefits for death, sickness or injuries resulting from suicide, attempted suicide or intentionally self-inflicted injury.

    War or Act of War – We will not pay benefits for death, sickness or injuries resulting from war or any act of war (whether declared or undeclared); participation in a riot or insurrection; or service in the Armed Forces or units auxiliary thereto.

    Worker’s Compensation – We will not pay benefits where such benefits would be provided under any State or Federal workers’ compensation, employers’ liability or occupational disease law.

    Pre-Existing Condition Limitation – There is no coverage for, nor will we pay benefits for death, Sickness or injuries related to, a pre-existing condition for a continuous period of 12 months following the Certificate Effective Date of coverage under this coverage.

    This limitation applies to the following benefits:

    • Hospital Confinement Benefit
    • Emergency Room Benefit
    • Doctor’s Office Visit Benefit
    • Diagnostic Tests Benefit
    • Hospital Intensive Care Unit Confinement Benefit
    • Surgery Benefit
    • Ambulance Benefit

    This limitation does not apply to:

    • Genetic information in the absence of a diagnosis of the condition related to such information;
    • A newborn child who is enrolled in the plan within 31 days after birth; nor to a child who is adopted or placed for adoption before attaining 26 years of age.