While individual benefit provisions have exclusions and limitations which pertain only to those benefits, there are some general exclusions and limitations that pertain to all benefits:

  1. Declared or undeclared war
  2. Any act of war
  3. Injury or Sickness arising out of employment
  4. Services or Supplies which are not recommended by a physician; (in the case of Dental Benefits, services or supplies which are not recommended by a Dentist)
  5. Intentionally self-inflicted injury unless determined by a diagnosis to be as a result of an underlying medical condition, such as depression
  6. Charges incurred in connection with cosmetic treatment, except if caused by injury. Cosmetic treatment will be considered unnecessary unless the treatment is necessary to ameliorate a (i) deformity arising from or directly related to a congenital abnormality, (ii) a disfiguring disease or (iii) if a participant or beneficiary is receiving benefits in connection with a mastectomy, the plan will also provide coverage for: Reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and physical complications at all stages of mastectomy, including lymphedemas. For this purpose, cosmetic treatment includes any procedure which is directed at improving the patient’s appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease
  7. Intersex surgery or fertility treatment
  8. Charges a participant would not be required to pay if there was no coverage under this Plan
  9. Charges incurred in connection with any altercation or commission of a crime
  10. Charges incurred prior to the date the Participant is eligible for benefits under the Plan provisions or for charges incurred after the Participant’s benefits have been terminated
  11. Charges for services which are eligible to be covered under the laws of a nation, state, province or local government of any country, whether or not the patient asserts his rights to obtain such coverage
  12. Charges for services necessitated by a motor vehicle accident to the extent that such services are payable under the Personal Injury Protection or compulsory medical payments provisions of an automobile insurance policy pursuant to any federal or state law requiring such coverage regardless of fault, whether or not You assert Your rights to obtain such coverage
  13. Charges for an accident or injury occurring at a school if the Participant and/or Dependent is covered by school insurance
  14. Eye Examination for eyeglasses only, except for Vision Care Benefit on page 36.
  15. Charges for glasses or contact lenses, except for Vision Care Benefit, and except contact lenses required because of surgery
  16. Charges made by a relative of You or Your Dependent who is also a medical provider
  17. Charges for any period of custodial care which is that type of care, wherever furnished and by whatever name called, which is designed primarily to assist an individual in meeting his activities of daily living
  18. Charges for dental care except:
    1. That are required by an injury; and
    2. Expenses incurred within 6 months of the injury (SEE DENTAL BENEFITS PAGE 30)
  19. Charges incurred in connection with the treatment of infertility. including, but not limited to, any of the following procedures:
    1. Artificial Insemination
    2. In Vitro Fertilization; or
    3. In Vivo Fertilization
  20. Charges for hearing aids only, except for Hearing Care Benefit on Page 41.
  21. Charges for treatment in a residential treatment center or long-term care facility
  22. Charges for genetic testing
  23. Charges for infant formula
  24. Charges for Chiropratic Treatment