MEDICAL EXCLUSIONS AND LIMITATIONS

Pre-existing Conditions
This plan contains a 12 month Pre-Existing Condition Limitation period during which time pre-existing conditions are excluded from coverage. A “Pre-Existing Condition” is a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 months immediately prior to the first day of coverage, or if there is a waiting period, the first day of the waiting period. The pre-existing condition limitation does not apply to pregnancy, newborns or adopted children or children placed for adoption enrolled within 30 days of birth, adoption or placement for adoption, or genetic information unless there is a diagnosis related to the information. If an employee or dependent enrolls as a Late Enrollee, or during a Special Enrollment Period, for the purpose of reducing the pre-existing condition limitation period, any period before such late or Special Enrollment Period is not a waiting period and the pre-existing condition limitation period will not be reduced by any such period.

Full or partial credit will be given towards the satisfaction of the pre-existing condition exclusion period, for the period of time a person was covered under prior creditable coverage. In order to receive credit, a person must have had no break or gap in coverage of more than 63 days prior to the person enrolling in this plan. This applies to all employees on the date of transfer as well as to new enrollees.

Prior Creditable Coverage
Creditable coverage is prior coverage a person had under: any group health plan (including FEHBP, COBRA, Peace Corps etc.), an individual health plan, Medicare, Medicaid, CHAMPUS or any other military health care, a state health benefits risk pool, Indian Health Service or tribal organization coverage, or any public health plan, as defined in the regulations. The employee must enroll for coverage in this plan within 31 days of becoming eligible, subject to the satisfaction of any waiting period. Any waiting period included in this plan must be met before the employee becomes insured. Any such waiting periods run concurrently with the pre-existing condition limitation period.

Other Exclusions and Limitation
No payment will be made for the following unless otherwise noted:

• Medical care not approved by a doctor; received in a U.S. Government facility, except for non-service connected disabilities; or for which the insured without this insurance would not be legally obligated to pay.
• Cosmetic treatment, except under certain conditions.
• Dental care or treatment, but we do cover:
  • hospital services provided while hospital confined.
  • dental care or treatment up to 24 months for injury to the jaw or sound natural teeth, and
  • dental care or treatment because of congenital disease or birth defect; and
  • doctors charges for the removal of up to 4 impacted teeth.
• Hearing aids, eye refractions, eyeglasses, contact lenses or their fittings, except for the first pair of eyeglasses or contact lenses prescribed after cataract surgery.
• Any injury or sickness due to war or armed conflict.
• Medical care of an injury due to taking part in a felony.
• Any injury or sickness sustained in the course of employment or covered by Workers' Compensation or a similar law, unless the insured is not eligible for coverage under such law.
• Services furnished, requested, or referred by a person who is the insured or insured's spouse, or a member of the insured's or insured’s spouse’s immediate family.
• Medical Care received while outside the United States, its possessions, or the countries of Mexico and Canada, except for the first 60 days of such an absence.
• Care provided by the insured's or dependent's employer, labor union or similar group, for which no charge would normally be made in the absence of this insurance.
• Experimental, investigative, developmental or educational medical care.
• Infertility services, except those included under Covered Expenses.
• Custodial care.
• Routine health exams, physical checkups or preventive care, except those services included under Covered Expenses.
• Routine treatment of feet, except for those services included under Covered Expenses.
• Medical Care of an injury to an insured while intoxicated or under the influence of drugs, narcotics or medicines, except if taken on the advice of a doctor.