- Charges for services or
supplies not listed in the covered medical services
provision; charges for complications of treatment or
surgery resulting from an excluded service or procedure;
charges for complications resulting from the covered
person leaving an inpatient or outpatient facility
against the advice of the covered person's physician.
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- Charges for drugs or
medications.
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- Free treatment or charges
that, in the absence of our coverage, the covered person
is not required to pay.
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- Charges for missed
appointments and provider administrative fees.
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- Charges for the services
of a standby physician except in limited circumstances.
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- Charges for treatment of
the covered person's intentionally self-inflicted
illness or injury, whether sane or insane.
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- Charges for treatment of
an illness or injury caused by or contributed by: (a)
employment; (b) the participation in the military
service; (c) war or act of war, (d) commission of a
felony; or (e) participation in illegal activities or
riot.
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- Charges for treatment of
an illness or injury that occurs while the covered
person has been under the influence of illegal narcotics
or non-prescribed controlled substance.
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- Charges for injury
sustained while: (a) participating in any
intercollegiate sport; (b) traveling to or from such
sport as a participant; or (c) participating in any
practice or conditioning program for such sport.
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- Charges for cosmetic
treatment or surgery and any complications arising from
such treatment or surgery.
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- Charges for hearing aids;
eyeglasses; contact lenses; eye exams; eye refraction;
eye surgery for correction of refraction error,
orthotics or corrective shoes; repairs to or prosthetic
devices; or routine foot care.
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- Charges for normal
pregnancy or childbirth, cesarean sections or routine
newborn nursery care; genetic testing, counseling or
therapy including but not limited to, amniocentesis and
chorionic villi testing; intrauterine or fetal treatment
or surgery; abortion; except as provided in the
Complications of Pregnancy Provision; treatment of
sexual dysfunction; transsexual surgery; infertility
diagnosis and treatment; oocyte retrieval; artificial
insemination; in-vitro fertilization; surrogate
pregnancy; fees associated with sperm banking; and
sterilization or reversal of sterilization.
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- Charges for treatment,
medications or hormones and any other treatment or
surgery for weight control or obesity.
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- Charges for treatment of
psychiatric conditions or substance abuse.
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- Charges for dental
treatment including dental braces or appliances to a
sound tooth.
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- Charges for services
rendered by or supplies purchased from a member of the
covered person's extended family or a person residing
with the covered person.
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- If the covered person is
eligible for Medicare, that part of any charge for which
a benefit would be paid under Medicare to a person
enrolled under Parts A and B of Medicare, regardless of
whether such person actually was enrolled. This does not
apply when the benefits of this plan are, by law,
primary to those of Medicare.
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- Charges for treatment,
repair or removal of the tonsils or adenoids.
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- Charges for services
rendered and supplies received which are not for
treatment of illness or injury.
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- Charges for living
expenses; and travel or transportation expenses.
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- Charges for treatment of
chronic pain disorders; biofeedback; aversion therapy;
custodial care; self help programs; services of a
non-physician surgical assistant; services rendered by a
masseur, masseuse or rolfer; health club membership fees
or exercise equipment.
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- Charges for experimental
or investigational services.
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- Charges incurred outside
of the United States or its possessions or Canada.
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- Charges for which we are
unable to determine our liability because you failed to
provide us with the necessary information.
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- Charges incurred during a
hospital confinement prior to surgery unless the
admission is medically necessary for an emergency.
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- The first $500 of
otherwise covered charges not authorized in accordance
with the Benefit Management Program provision or any
expense for an organ transplant if the procedure was not
authorized prior to any organ evaluation, testing or
donor search.
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- Charges incurred after
coverage terminates.
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- Charges incurred for a
condition for which there is other liability insurance
providing medical payments or medical expense coverage.
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