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Home > Health Plan > D5 - Exclusions
GENERAL EXCLUSIONS AND LIMITATIONS
This Plan contains some general exclusions and limitations that apply to all benefits provided by the Plan. No benefits are payable under the Plan for the following:
- accidental injury or sickness arising out of or in the course of employment, or which is compensable under any Workers’
Compensation or Occupational Disease Act or Law, except in the case of Life and AD&D benefits
- services, supplies or treatments that are not medically necessary
- services or supplies that are experimental or investigative or do not meet accepted standards of medical practice
- expenses incurred while coverage is not in force
- accidental injury or sickness caused by war or any act of war, declared or undeclared, or by participating in a riot, or as
the result of the commission of a felony
- examinations or treatment ordered by a court in connection with a legal proceeding or obtained for the purpose of
receiving favorable consideration by a court or similar body, unless such examinations or treatment would otherwise qualify
as a covered expense.
- any charges that exceed the usual and customary charges
- any expenses over maximum benefit amounts
- expenses that you would not have been charged had there been no coverage
- expenses for which there is no legal obligation or financial liability to pay
- physical examinations or medical certificates required for employment
- any hospital confinement, operation or other service that meets one of the following criteria:
- is provided in a U.S. government hospital or in any other hospital operated by a government unit,
except for those provided by the Veterans Administration when services are provided to a veteran for a disability that is
not service-connected, or unless you or your eligible dependent is legally required to pay
- is not recommended and approved by a legally qualified physician or surgeon
- is not medically necessary
- is experimental or investigational in nature
- exceeds the usual and customary charge
- is received outside the United States or Canada, except for emergency care
- diagnosis, testing or treatment of infertility
- diagnosis, testing or non-surgical treatment of obesity, except that other appropriate treatment will be covered when
acceptably certified by a qualified physician as morbid obesity due to body weight in excess of 100 pounds over ideal body
weight (or 100% over ideal body weight if body weight is less than 100 pounds), as determined by the Trustees. Generally,
morbid obesity occurs when the Body Mass Index (BMI) calculation is 40 or higher. The criteria for surgical treatment of
obesity is described in the Comprehensive Medical Expense Benefit section under
Obesity Surgery.
- reversal of a surgical procedure
- services provided by a person who normally resides in your household or who is a parent, spouse, child, brother or
sister of the eligible employee-member or his or her dependent
- educational services, supplies or equipment, including but not limited to, computers, software, printers, books, tutoring
and visual aids even if they are required because of an injury or illness
- dental treatment, except as provided under the Dental Benefit, and except for removal of tumors, treatment of fractures,
direct surgery on the temporomandibular joint itself or surgery to correct a malocclusion of the jaw due to a skeletal deformity
- expenses for which the Fund has not received complete documentation of the claim, including medical reports and
records if needed.
- If you are employed by more than one employer participating in this Fund, the benefits provided to you will be no greater
than if you were employed by only one employer.
- If you or your eligible dependent are covered under more
than one plan classification, the benefits provided will be payable under the plan classification providing the largest benefit.
- expenses payable by another group medical plan under the Plan’s Coordination of Benefits
provision
- charges for failure to keep a scheduled visit, completion of a claim form or routine supplemental report, phone calls,
handling fees and personal items
- charges from a doctor for more than one office visit on the same day
- anything excluded under any other provision of the Plan
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