1980 002 Ordinance - Laserfiche WebLink

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EXCLUSIONS AND LIMITATIONS (Other than Dental Expense Insurance) The Major Medical Expense Benefits under the plan do not cover- Charges for hearing aids, hearing examinations. War-Any charges due to declared or undeclared war, including resistance to armed aggression. Charges resulting from pregnancy, except for certain complications of pregnancy, and then only to the extent such charges are not covered under the Optional Maternity Benefit, if included. Newborn Child's Room and Board-Charges for room and board during the seven days following birth unless necessitated by a diagnosed illness. None of the health care benefits covers the following: Occupational Injury or Disease-Charges in connection with injury or disease recognized as a compensable loss by the provisions of any workers' compensation, occupational disease or similar law. Government Plan-Charges for a service or supply (a) furnished by or for any government, unless the government is other than the U.S. government and payment is legally required, or (b) to the extent any benefit is provided by any law or governmental program under which you are or could be covered. Non-essentials; Check-ups-Anything not orderd by a doctor or not reasonably necessary for medical care of illness; check-up examinations and tests not reasonably necessary to medical treatment. Excess Charge-Any charge for a service or supply to the extent to which it exceeds the smaller of (a) the usual charge made by the provider when there is no insurance and (b) the general level of charges for a comparable service or supply made by other providers within the same county (or larger area if necessary to get a representative cross-section). Charges for: certain mouth and foot conditions; eyeglasses, eye examinations. Charges resulting from pregnancy, except for certain complications of pregnancy, and then only to the extent such charges are not covered under the Optional Maternity Benefit, if included. Deductibles-Charges used to satisfy required deductibles. See "Other Benefits" and "Limited Medical Expense Benefit." Eligible charges are those incurred while a person is covered under the plan. A charge is considered to be incurred on the date of the service or purchase for which the charge is made. This plan contains a provision coordinating it with coverage the person has under other plans. The provision is designed to guard against over-payment of actual expenses and helps to control the cost of the benefits for everyone. Weekly Disability Income coverage under the plan does not cover- Elimination Periods-Benefits will not begin until day shown on Summary of Benefits. Workers' Compensation-Benefits do not cover disabilities caused by sickness or injuries covered under workers' compensation. Accidental Death and Dismemberment coverage under the plan does not cover- On the job injury when the Summary of Benefits indicates "Off the job only. Limited Medical Expense Benefit under the plan does not cover- Expense to the extent payable under Medicare. Other limitations and exclusions are included in the description of benefits appearing in the preceding pages. (See definitions of Hospital and Convalescent Nursing Home which follow.) 11