Limitations And Exclusions

Benefits will not be provided for the following:

• Incremental nursing charges which are in addition to the Hospital's standard charge for Bed, Board and General Nursing Service.
• The amount of charges for luxury accommodations or any accommodations in any Hospital or Allied Health Facility provided primarily for the patient's convenience which exceeds the Allowable Charge for a standard Hospital room.
• Bed and Board in any other room at the same time Benefits are provided for use of a Special Care Unit.
• Prescription Drugs that are determined by the Administering Insurer not to be Medically Necessary for the treatment of illness or injury. The drugs include but are not limited to the following:
  • Drugs used for cosmetic purposes or weight reduction.
  • Any medication not proven effective in general medical practice including any drug used for smoking cessation.
  • Investigative drugs and drugs used other than for the FDA approved diagnosis.
  • Fertility drugs.
  • Minerals and vitamins (Exception: pre-natal vitamins).
  • Nutritional supplements.
  • Immunizations for prevention of infectious diseases (measles, polio, etc.).
  • Drugs that do not require a prescription.
  • Contraceptive devices (Exception: prescription contraceptives). Although IUD's and Diaphragms require a prescription, these products are contraceptive devices and, therefore, are not covered under this Policy.
  • Prescription Drugs if an equivalent product is available over the counter.
  • Refills in excess of the number specified by the Physician or any refills dispensed more than one year after the date of Physician's original prescription.
• Outpatient Occupational Therapy.
• Treatment related to sex transformations, sexual function, sexual dysfunctions or inadequacies regardless of Medical Necessity.
• Elective abortions including, however not limited to, the Policyholder's request for payment of prescription abortifacients (Exception: Upon proper documentation from the Policyholder's Provider, Administering Insurer may determine that the elective abortion procedure was Medically Necessary in order to preserve the life or physical health of the mother).
• Services and supplies related to infertility, artificial insemination, intrauterine insemination and in vitro fertilization regardless of any claim of Medical Necessity.
• Provider services or supplies rendered or furnished prior to the Policyholder's Effective Date or subsequent to the Policyholder's termination date.
• Charges for services paid or payable under Medicare when the Policyholder has Medicare coverage.
• Charges for services paid or payable under Medicaid.
• Charges for services paid or payable under Veterans benefits.
• Provider services, supplies, or charges to the extent payment has been made or is available under any other contract issued by any other insurer, or to the extent provided for under any other group policy.
• Acupuncture, anesthesia by hypnosis, or charges for anesthesia for non-covered services.
• Cosmetic Surgery and any complications of Cosmetic Surgery.
• Services or expenses for which the Policyholder has no legal obligation to pay, or for which no charge would be made if the Policyholder had no health coverage.
• Services or supplies which are not prescribed by or performed by or upon the direction of a Physician or Allied Health Professional.
• Services or supplies other than those specifically covered by this Policy.
• Services or items which are Investigative or experimental in nature.
• Any injury, illness or condition for which a claim has been or will be pursued under any worker's compensation laws. If no claim has been or will be pursued or where there is ultimately no recovery of any type under the applicable worker's compensation laws, Benefits of this Policy will be available.
• Any injury growing out of an act or omission of another party for which a claim or recovery is or will be pursued. If no claim or recovery is or will be pursued, Benefits otherwise will be available under the terms of this Policy.
• Care provided by any governmental Hospital such as a charity Hospital, mental institution or sanatorium, except in those cases where enforcement of this exclusion would be prohibited by Federal law or the laws of the State of Mississippi.
• Diseases contracted or injuries sustained as a result of war, declared or undeclared, or any act of war.
• Care received from a dental or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust, or similar person or group.
• Care rendered by a Provider who is related to the Policyholder by blood or marriage or who regularly resides in the Policyholder's household.
• Personal comfort, personal hygiene and convenience items such as, but not limited to, air conditioners, humidifiers, or personal fitness equipment.
• Charges for telephone Consultations, failure to keep a scheduled visit, completion of a claim form, or to obtain medical records or information required to adjudicate a claim(s).
• For palliative or cosmetic foot care including flat foot conditions, supportive devices for the foot, care of corns, bunions (except capsular or bone Surgery), calluses, toenails, fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet, except for preventive or routine foot care rendered to a Member with a diagnosis of Diabetes.
• Medical exams and/or diagnostic tests for routine or periodic physical examinations and screening examinations and for immunizations.
• Any surgical procedure that is performed in order to correct a visual acuity defect that can be corrected by contact lens or glasses is not eligible for coverage.
• Travel, whether or not recommended by a Physician, except as specified under Ambulance Services Benefits and Organ Transplant Benefits.
• Weight reduction programs or treatment for obesity including any Surgery for morbid obesity or for removal of excess fat or skin following weight loss, regardless of Medical Necessity, or Services at a health spa or similar facility.
• Treatment of any Policyholder confined in a prison, jail, or other penal institution.
• Treatment of any Policyholder who is a resident or inmate in a public mental health facility or any other public institution.
• Charges for eyeglasses, contact lenses, eye exercises, orthoptic therapy, hearing aids or for examination or fitting regardless of Medical Necessity (Benefits will be provided for dilated eye exams rendered to policyholders with a diagnosis of Diabetes.)
• Home Health Care services provided by a Home Health Care Agency.
• Nursing home care, custodial home care, skilled nursing or extended care facility services, regardless of the level of care required or provided.
• Hospice Care and Respite Care.
• Industrial testing or self help programs (including, but not limited to, smoking cessation programs, stress management programs).
• Work hardening programs.
• Any care or service not specified as a Covered Service.
• Hospital, surgical or medical services rendered in connection with the pregnancy of a dependent child.
• Care of a newborn.
• Provider services or supplies which are not documented to be Medically Necessary as determined by the Administering Insurer.
• Inpatient Hospital services and supplies for Rehabilitative Care and treatment except when such care is rendered while a patient is receiving Acute Care for a disease or injury.
• Charges related to any Pre-existing Condition until this Policy has been in effect as to the Policyholder for whom such Benefits are sought for the pre-existing condition exclusionary period shown on the Policy Specifications page of this Policy.
• Charges related to any pregnancy until this Policy has been in effect as to the Policyholder for whom such Benefits are sought for the pregnancy benefit waiting period shown on the Policy Specifications page of this Policy.
• Charges relating to any Prescription Drugs until this Policy has been in effect as to the Policyholder for whom such Benefits are sought for the pharmacy benefit waiting period shown on the Policy Specifications page of this Policy.
• Preventive Services or Wellness Services, except as provided in this policy.
• For reversal of a voluntary sterilization procedure.
• Charges for Ambulance Service provided for the Policyholder's convenience.
• Counseling services related to treatment of Nervous/Mental Conditions.
• Organ or bone marrow transplants except as considered on an individual basis and approved by the Association and the Administering Insurer.
• For any loss which is due to or results from the Policyholder's commission of or attempt to commit an assault, felony or other illegal act.
• For any loss which is due to or results from the Policyholder's engaging in any illegal occupation.
• For any loss which is due to or results from the Policyholder's intentional self inflicted injury.
• Services, care, treatment or supplies which are furnished or rendered after the cancellation or termination date of the Policyholder's coverage (whether or not such services, care, treatment or supplies are for or related to a condition, disease, ailment or injury which commenced before or existed on the termination date of the Member's coverage).
• Speech Therapy.
• Private Duty Nursing Services.
• Dental Care and Treatment.
• Drugs and medications that are prescribed by a Provider in order to enhanced the Member's performance in certain activities (example: blood enhancing drugs).
• Inpatient and Outpatient Newborn Well Baby Care.
• Temporomandibular/Craniomandibular Joint Disorder.
• Charges for all medical complications, which arise as a result of the Policyholder receiving Non-covered Services. Examples of Non-Covered Services include, but are not limited to, gastric bypass surgery, liposuction, cosmetic surgery, and elective abortions.
• Prescription drugs when the Policyholder is eligible for Medicare benefits.
• Antihemophilic factor, factor VIII, factor IX, factor concentrate or factorate products of any kind and services or supplies related thereto received on an Outpatient basis.

[ Capitalized terms are defined in the major medical expense policy issued by the association. ]