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13.

Injuries resulting from a motor vehicle accident to the extent that benefits are payable under other valid and collectible insurance whether or not a claim is made for such benefits;

14.

Treatment of mental or nervous disorders except as specifically provided;

15.

Treatment of alcohol and drug abuse except as specifically provided;

16.

Elective abortions;

17.

Routine physical examinations and routine testing; preventive testing or Treatment; screening examinations or testing in the absence of Injury or Sickness;

18.

Expense incurred after the date of insurance terminates for an Insured Person except as may be specifically provided in the Extension of Benefits Provision;

19.

Participation in, practice for, or orthopedic equipment and appliances used for; intercollegiate sports or professional sports;

20.

The diagnosis and treatment of TMJ dysfunction, or skeletal irregularities of one or both jaws, including orthognathia and mandibular retrognathia;

21.

Expenses incurred in connection with birth control, including surgical procedures and devices diagnosis and treatment;

22.

Charges used to meet any deductible, or in excess of the coinsurance level, or an amount of a charge in excess of the Usual, Customary and Reasonable Charges;

23.

Treatment or services provided by any member of the Covered Person's immediate family; or for which no charge is normally made;

24.

Services not Medically Necessary;

25.

Injury sustained as a result of riding in or on a two or three-wheeled motor vehicle, or riding in or on a snowmobile.

CLAIM PROCEDURE

In the event of an Injury or Sickness the Insured Person should:

1. The physicians and hospitals may submit itemized bills directly to ACI electronically using Payor # 22384 or mailing them to the address below.

1 5 2 . C o m p l e t e a c l a i m f o r m a n d m a i l i t t o A C I w i t h i n 3 0 d a y s o f t h e d a t e o f t h e I n j u r y o r c o m m e n c e m e n t o f t h e S i c k n e s s , o r a s s o o n t h e r e a f t e r a s p o s s i b l e . M a i l t h e c l a i m f o r m t o A d m i n i s t r a t i v e C o n c e p t s , I n c . , 9 9 4 O l d E a g l e S c h o o l R o a d , S u i t e 1 0 0 5 , W a y n e ,

3 . C l a i m f o r m s a r e a v a i l a b l e o n l i n e a t w w w . v i s i t - a c i . c o m o r b y c a l l i n g 8 8 8 - 2 9 3 - 9 2 2 9 . I f t h e p r o v i d e r s h a v e g i v e n y o u b i l l s , a t t a c h t h e m t o t h e c l a i m f o r m .

4 . D i r e c t a l l q u e s t i o n s r e g a r d i n g b e n e f i t s a v a i l a b l e u n d e r t h i s P l a n , c l a i m p r o c e d u r e s , s t a t u s o f a s u b m i t t e d c l a i m o r p a y m e n t o f a c l a i m t o A C I . O n l i n e c l a i m s t a t u s i s a v a i l a b l e a t w w w . v i s i t - a c i . c o m o r b y c a l l i n g 8 8 8 - 2 9 3 - 9 2 2 9 . S e l e c t o p t i o n 2 f o r C u s t o m e r S e r v i c e .

5

. I t e m i z e d m e d i c a l b i l l s m u s t b e a t t a c h e d t o t h e c l a i m f o r m a t t h e t i m e o f s u b m i s s i o n . S u b s e q u e n t m e d i c a l b i l l s r e c e i v e d a f t e r t h e i n i t i a l c l a i m f o r m h a s b e e n s u b m i t t e d s h o u l d b e m a i l e d p r o m p t l y t o A C I . N o a d d i t i o n a l c l a i m f o r m s a r e n e e d e d a s l o n g a s t h e I n s u r e d P e r s o n s n a m e a n d i d e n t i f i c a t i o n n u m b e r a r e i n c l u d e d o n t h e b i l l .

REIMBURSEMENT AND SUBROGATION

If We pay covered expenses for an accident or injury You incur as a result of any act or omission of a third party, and You later obtain recovery from the third party, You are obligated to reimburse Us for the expenses paid. We may also take subrogation action directly against the third party. Our Reimbursement rights are limited by the amount You recover. Our Reimbursement and Subrogation rights are subject to deduction for the pro-rata share of Your costs, disbursements and reasonable attorney fees. You must cooperate with and assist Us in exercising Our rights under this provision and do nothing to prejudice Our rights.

APPEALS

If a claim is wholly or partially denied, a written notice will be sent to the Insured Person containing the reason for the denial. The notice will include a reference to the provision in the Plan description and a description of any additional information, which might be necessary for reconsideration of the claim. The notice will also describe the right to appeal.

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