General exclusions

1. Any service, treatment or supply that is not considered medically necessary as defined by the plan.
2. Expenses incurred after the end of a Benefit Period, even if incurred for continuing services or treatment of a covered injury.
3. Benefits provided by a Government plan (except Medicaid and other public assistance plans).
4. Injuries compensable under Workers’ Compensation law or any similar law.
5. Intentionally self-inflicted Injury, suicide or any attempt or threat while sane or insane.
6. Declared or undeclared war or act of war.
7. Commission or attempt to commit a felony or an assault.
8. Commission of or active participation in a riot or insurrection.
9. Treatment of a pre-existing condition.
10. Flight in, boarding or alighting from an aircraft, except as a fare-paying passenger on a regularly scheduled commercial or charter airline.
11. Travel in or on any on-road and off-road motorized vehicle that does not require licensing as a motor vehicle.
12. An accident if the covered person is the operator of a motor vehicle and does not possess a valid motor vehicle operator’s license, unless: (a) The covered person holds a valid learner’s permit and (b) The covered person is receiving instruction from a Driver’s Education Instructor.
13. Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a physician and taken in accordance with the prescribed dosage.
14. Treatment in any Veteran’s Administration, Federal, or state facility, unless there is a legal obligation to pay.
15. Operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it. Under the influence of alcohol, for purposes of this exclusion, means intoxicated, as defined by the law of the state in which the covered accident occurred.
16. Rest cures, long-term care or custodial care.
17. Cosmetic surgery or care, or treatment solely for cosmetic purposes, or complications therefrom. This exclusion does not apply to:
         a. Cosmetic surgery resulting from a covered accident, if the covered person’s initial treatment had begun within 12 months of the date of the covered accident;
         b. Reconstruction incidental to or following surgery resulting from a covered accident.
         c. Any unplanned and unintended adverse consequences that may result during the treatment of a covered accident.
18. Any elective or routine treatment, surgery, health treatment, or examination, including any service, treatment or supplies that: (a) Are deemed to be experimental or investigational; and (b) Are not recognized and generally accepted medical practice in the United States.
19. Services or treatment provided by persons who do not normally charge for their services, unless there is a legal obligation to pay.
20. Treatment or services provided by the covered person’s immediate family.
21. Orthopedic appliances used mainly to protect an injury
22. Expenses payable by any automobile insurance policy without regard to fault.
23. Treatment of injuries that result over a period of time (such as blisters, tennis elbow, etc.), and that are a normal, foreseeable result of participation in the covered activity.
24. Charges for hot or cold packs for personal use
25. Custodial Care service and supplies.
26. Expenses that are not recommended and approved by a physician.
27. Repair or replacement of existing artificial limbs, eyes and larynx, unless damaged or destroyed in a covered accident.
28. Any expenses in excess of usual and customary charges.
29. Loss resulting from playing, practicing, traveling to or from, or participating in, or conditioning for, any professional sport.

Note: Certain exclusions may be modified to meet individual state requirements. This is not a complete list of exclusions. The issued policy will contain the complete list of the exclusions applicable to the Group’s plan.

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