General Limitations And Exclusions

Summary

The following is a list of services and supplies which are limited or not covered by this plan.

All benefits are subject to the provisions, definitions, and limitations and exclusions of this plan. Please refer to the specific benefit description for additional limitations and exclusions. A service or supply not expressly included in this plan booklet is not a covered benefit, even if it is not specifically excluded below. No benefits are provided for the following or for any direct or indirect complications or consequences thereof, unless specifically stated otherwise below or unless specifically provided for in the description of the benefit:

1. Services or supplies not considered medically necessary, except as provided for under Preventive Care. The fact that a procedure, service or supply may be furnished, prescribed, recommended, or approved by a provider does not, in itself, make it medically necessary or make the charge a covered expense, even though it is not specifically listed as an exclusion. A service or supply may be medically necessary in part only.
2. Charges exceeding the usual, customary and reasonable charge as determined by this plan.
3. Services or supplies not recommended and approved by a covered physician or other covered provider; elected by the individual and not approved by the covered physician or other covered provider; not covered as a result of a benefit reduction under the medical review program; exceeding benefit maximums; or not specifically mentioned as covered by this plan.
4. Services or supplies outside the scope of the provider’s license, registration or certification, or that are furnished by a provider that is not currently licensed, registered or certified by the jurisdiction in which the services or supplies were received.
5. Services or supplies that are experimental or investigative, or related complications.
6. Any claim for services or supplies received by the Trust Office 12 months or more after the date of service.
7. Services or supplies that qualify under more than one provision. The plan reserves the right to determine under which provision payment is made. In no event will an expense be covered under more than one provision of this plan.
8. Services or supplies received or ordered when a plan benefit is not in effect, or when the individual is not covered under this plan.
9. Services or supplies not substantiated by medical records; charges for failure to keep a scheduled appointment; charges for telephone consultations; or charges for the completion or submission of any forms, reports or medical records including the preparation and presentation of medical or psychological reports or physical examinations required primarily for the protection and convenience of the individual or third party.
10. Inpatient hospital services (including physician’s visits while hospitalized) when the admission is not medically necessary and the service could be provided in a lesser facility, such as a hospital outpatient department, physician’s office or ambulatory surgical facility, etc., without adversely affecting the patient’s physical condition. Such admissions include, but are not limited to the following:
    1. Admissions primarily for observation or diagnostic studies that could be provided safely and adequately on an outpatient basis.
    2. Admissions for surgery, when the surgery could be safely and adequately performed on a same-day basis in a hospital, physician’s office or independent ambulatory facility.
    3. Psychiatric admissions which are primarily to control or change the individual’s environment when care could be provided safely and adequately on an outpatient basis or in a lesser facility than a hospital.
11. Expenses incurred as a result of direct or indirect complications, consequences or after-effects, whether immediate or delayed, that arise from any condition, service, or supply that is not covered under this plan, except as specifically stated by this plan.
12. Services or supplies for a nervous or mental disease or disorder whether the cause is organic, physical, mental, or environmental including, but not limited to, conditions which fall within the range of diagnostic codes 290.0 through 319.9 as listed in the current edition of the International Classification of Diseases Manual, except as provided for under Mental Health Care.
13. Hospitalization for routine dental services, except when preauthorized and approved by the Trust Office.
14. Illnesses, injuries or conditions arising out of, or occurring in the course of, any occupation for wage or profit, even if the patient fails to make timely application for  workers’ compensation benefits or waives his or her rights to those benefits. This includes benefits from occupational insurance purchased by an employer, benefits provided under state or federal workers’ compensation acts, employer liability laws, or other laws providing compensation for work-incurred illnesses or injuries, even if such benefits are recoverable through adjudication or settlement.
15. Services or supplies for which there are no charges made to the individual or for charges that would not have been made or that the individual would have had no obligation to pay in the absence of this plan, Medicare, or any federal, state or governmental program, except where required by law. This provision does not apply to benefits payable under Medicare at any time when compliance with federal law requires that the benefits of this plan must be determined before benefits are available under Medicare.
16. Confinement, surgical, medical, or other treatment, or services or supplies received in or from a U.S. government hospital, except as required by law.
17. Charges or lost wages that result from an illness or injury caused by the act or omission of another person (known as the “third party”) if the retiree, spouse or dependent child recovers from the third party or third party’s insurer, under an automobile, commercial premises, homeowners, medical malpractice, renters, or any other insurance coverage or liability policy. This includes recovery from the retiree’s, spouse’s or dependent child’s first party coverage under an automobile policy, except as provided for under Trust’s Right To Reimbursement (Third-Party Liability).
18. Illness or injury caused by war or any act of war, declared or undeclared, or service in the armed forces of any country.
19. Intentionally self-inflicted injuries, or injuries self-inflicted or sustained during suicides or attempted suicides, unless the injuries were the result of a medical condition (physical or mental).
20. Illnesses or injuries sustained in the following circumstances:
    1. While engaged in any activity that results in committing an assault, battery or felony.
    2. While performing any acts of violence or physical force that would not be performed by a reasonably prudent person in similar circumstances.
    3. While participating in a riot.
    4. Recreational use of, abuse of or overdose of legal, illegal or over-thecounter drugs or other substances, whether or not the act was intentional.
       
       Being under the influence of a chemical substance will not be considered to affect the individual’s ability to form intent.
21. Court-ordered care or assessments; care in lieu of incarceration; residential treatment centers; detention centers; reform schools; programs such as “outward bound” or “wilderness survival”; recreational, vocational or educational therapy; or anger management classes.
22. Any injury sustained while practicing for or competing in a professional or semiprofessional athletic contest. Semiprofessional athletics means an athletic activity for gain or pay, that requires an unusually high level of skill and a substantial time commitment from individuals who are nevertheless not engaged in the activity as a full-time occupation.
23. Cosmetic surgery, reconstructive surgery, or plastic surgery, including services, supplies or drugs or any portion thereof which improves, alters or enhances the texture or appearance of the skin, or the relative size or portion of any part of the body whether or not for psychological or emotional purposes, or is not needed to correct or improve a bodily function. The following are examples of what are not covered services or supplies: surgery for sagging skin of the eyelids (blepharo-chalasis), face, neck, abdomen, hips, or extremities (meloplasty, rhytidectomy or lipectomy); reshaping of the nose (rhinoplasty) or ears (otoplasty); and silicon or collagen injections to any part of the body.
24. Biofeedback, except as provided for under Rehabilitative Care.
25. Custodial care; nonmedical self-help or related testing; exercise or maintenance level programs; work hardening; behavioral training; recreational, vocational, educational, or cognitive therapy; neuromuscular reevaluations, gym or swim therapy; sensory integration therapy; or therapy or maintenance which is solely for the purpose of slowing body degeneration rather than restoring functional improvement.
26. Services or supplies provided by an institution which is primarily a rest home, a home for the aged, a nursing home, a convalescent home, or any of like character.
27. Therapy to assist in the initial development of a motor or sensory skill including speech therapy for developmental disorders of articulation, except as provided for under Neurodevelopmental Therapy; self-correcting dysfunction such as hoarseness, or language therapy for young children with natural dysfluency, or therapy to correct developmental or emotional language delays; oral myofunctional therapy; stammering and stuttering; tongue thrust; sensory integration therapy; state-required medical assessments for specialized educational programs; services or supplies required by law to be provided by any school system; or treatment of learning disabilities or developmental delays. This exclusion applies regardless of the recommendation of the attending physician.
28. Services or supplies related to the correction of the gum, teeth or tissues of the mouth for dental purposes, including services or supplies related to the removal, repair, replacement, restoration, or repositioning of teeth lost or damaged in the course of biting or chewing, except as provided for under Dental Accidents or Oral Surgery.
29. Treatment of psychiatric conditions and eating disorders such as anorexia nervosa, bulimia or any similar conditions, except as provided for under Mental Health Care.
30. Vision related problems including, but not limited to: dyslexia; visual analysis therapy or training related to muscular imbalance of the eye; orthoptics including special purpose vision aids; subnormal vision aids; aniseikonic lenses; tonography; or radial keratotomy or any other eye surgery when the primary purpose is to correct refractive errors such as, but not limited to, myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring).
31. Services or supplies received by a retiree, spouse or dependent child which are recommended, prescribed or performed by an immediate family member, including a spouse, child, brother, sister, or parent of the retiree or of the retiree’s spouse.
32. The difference between the charge for a private room and a hospital’s average charge for a semiprivate room, unless medically necessary; private or special duty nurses, regardless of where the services are rendered; or room and board for any day in which the individual is released from the hospital on a temporary pass, or for any charge related to a late discharge from the hospital when the late discharge is for patient or provider convenience.
33. Services or supplies for pregnancy-related conditions (including routine testing) for dependent daughters including complications thereof, unless required by law.
34. Contraceptives (whether medication or device), family planning or contraceptive management.
35. Services or supplies in connection with the diagnosis or treatment of reproductive or sexual dysfunctions and defects whether or not the consequence of an illness or injury, including but not limited to, impotency (except as provided for under Erectile Dysfunction); frigidity; reversal of surgical sterilization; infertility, including but not limited to, in vitro fertilization, artificial insemination, embryo transfer, microinjections, zona drilling, or other artificial means of conception; fertility drugs (including, but not limited to, Clomid, Pergonal, Serophene, or HCG when associated with any artificial means of conception), consecutive follicular ultrasounds, cycle therapy and corresponding lab tests when associated with any artificial means of conception; or sex transformations.
36. Obesity treatment regardless of diagnosis, including weight control programs, dietary or nutritional services or supplies, surgery or complications of surgery, prescription drugs, or wiring of the jaw or similar procedures.
37. Diet substitutes or nutritional supplements or services, except as provided for under Infusion Therapy or dietary counseling or instructions (classes), except as provided for under Diabetic Care.
38. Personal convenience items including, but not limited to, telephones, televisions, guest accommodations, educational materials, bath aids, raised toilet seats, heating pads, enuresis (bed wetting) training equipment, whirlpool baths, exercise equipment, weights, keyboard communication devices, adjustable beds, three-wheeled scooters, customized car seats, strollers, orthopedic chairs, personal hygiene items, blood pressure devices, breast pumps, deluxe items such as motorized equipment, air conditioners, humidifiers, or air filter systems.
39. Acupuncture, naturopathic, homeopathic, holistic, hypnosis, clinical ecology, or herbalistic treatment by any provider; services of a massage therapist; hair, mineral, or gastric analysis; or chelation therapy (except for acute arsenic, gold, mercury or lead poisoning) by any provider.
40. Services or supplies in connection with routine foot care, including hygienic care; trimming of nails; paring, excision, cauterization, or radiation of corns or calluses; weak or fallen arches; flat or pronated feet; metatarsalgia; massage; casting, taping or manipulative procedures of the foot; over-the-counter orthotics including insoles, inlays or arch supports; or prescriptions for or purchase of foot orthotics or similar appliances or shoes including arch supports or casting for arch supports and corrective shoes (unless connected to a brace).
41. Any warranty or service contract; or freight, postage or delivery charges.
42. Services or supplies received by a Medicare-entitled retiree or spouse from a non-Medicare participating provider or facility is limited to the amount that would have been provided if such services or supplies were received from a Medicare participating provider or facility.
43. Marriage counseling, family counseling, career counseling, social adjustment counseling, pastoral counseling, or financial counseling.
44. Therapy prescribed by a chiropractor or a physical, speech, respiratory, or occupational therapist; or therapy elected by the individual but not prescribed by the attending physician prior to commencement of treatment.
45. Routine physical examinations, immunizations and other preventive services or supplies, except as specifically provided for under Preventive Care.
46. Services or supplies not covered by or received outside of any Medicare Managed Care Plan or Individual Medicare Supplemental Insurance (Medigap) area if the Medicare-entitled retiree or spouse participates in one of these plans.
47. If an individual is entitled to Medicare and participates in any  Medicare Managed Care Plan or Individual Medicare Supplemental Insurance (Medigap), coverage is not provided by the Retired Plan, except as specifically provided for under Prescription Drug Supplement.
48. Expenses incurred as a result of direct or indirect complications, consequences or after-effects, whether immediate or delayed, that arise from any body piercing, tattooing, or similar alteration.
49. Expenses incurred while an individual is in the custody of, or confined by, any law enforcement officer or agency.
50. Services or supplies that are not listed as covered under this plan.