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Medical Limitations and Exclusions

In addition to the benefit limitations and exclusions discussed elsewhere in this Plan Document, the following are either limited or not covered by the Plan.

Abortion

Acupuncture/Biofeedback Allowable Charge Assistant at surgery

Blood

Canceled or Missed Appointments Charity Hospital, Public Mental Institution, Sanatorium

Not covered, unless documented to be medically necessary to preserve the life or physical health of the mother. Not covered. Charges exceeding the allowable charge are not covered. Not covered, unless services are rendered by a physician. The first three (3) pints of blood used during each inpatient admission or outpatient service are not covered. Not covered.

Services for which the participant has no legal obligation to pay or for which no charge would be made if the participant had no health insurance coverage are not covered.

Chelation Therapy

Coding

Convalescent, Custodial, or Domiciliary care Co-payments, Coinsurance, Deductibles Cosmetic Services

Counseling

Coverage Effective Dates

Dental Services

Not covered, except for treatment of acute heavy metal poisoning. Charges resulting from inappropriate coding, as determined by Blue Cross & Blue Shield are not covered. Not covered, including companions and sitters.

Not covered.

Not covered, except for correction of defects incurred by a participant while covered under the Plan through traumatic injury or disease requiring surgery. Sex therapy and marriage or family counseling are not covered. Services or supplies provided before coverage becomes effective or after coverage ends are not covered. Not covered, except when services are provided due to an accidental injury to sound natural teeth which occurs while the participant is covered by the Plan or as a direct result of a disease covered by the Plan.

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