Limitations and Exclusions

HealthAssist Limitations and Exclusions

WHAT IS NOT COVERED UNDER MEDICAL AND ACCIDENTAL DEATH: LIMITATIONS FOR PRE-EXISTING CONDITIONS

A pre-existing condition is a condition for which the covered person has been medically diagnosed or treated by a physician or sought advice from or consulted with a physician during the 12 months before becoming insured under this plan. This type of condition will not be covered until the covered person has been insured under this plan for a continuous period of 12 months.

ACCIDENTAL DEATH EXCLUSIONS

In addition to the Medical Benefit Exclusions, no benefits are payable for loss resulting from:

• Suicide or a suicide attempt while sane or self-destruction or an attempt to self-destroy.
• Sickness, except pyogenic infections which occur through an accidental cut or wound. In West Virginia, sickness except pyogenic infections which occur due to an accident.
• Riding in, or boarding or alighting from, any aircraft owned, operated, chartered or leased by or on behalf of the Covered Persons employer.
• Riding in, or boarding or alighting from, any aircraft, except while a passenger on the aircraft for the sole purpose of transportation.

MEDICAL BENEFIT EXCLUSIONS

This Plan does not pay benefits for:

• Treatment, services or supplies which:
• Are not Medically Necessary;
• Are not prescribed by a Doctor as necessary to treat Sickness or Injury
• Are Experimental/Investigational in nature;
• Are received without charge or legal obligation to pay; or
• Treatment by any Family Member.
• Injury or Sickness arising out of or in the course of employment or which is compensable (in South Dakota, which is paid) under any Workers' Compensation or Occupational Disease Act or Law.
• Loss resulting from declared or undeclared war or any act of war.
• Loss resulting from the Covered Person's committing a felony.
• Intentionally self-inflicted Injury or Sickness.
• Any period of care designed to help a Covered Person in the activities of daily living not requiring continuous attention by trained medical or paramedical personnel. Such care may involve: the preparation of special diets; supervision over medication that can be self-administered; and assisting the person in getting in or out of bed, walking, bathing, dressing, eating, and using the toilet.
• Treatment of Mental or Nervous Disorders, alcoholism, or any form of substance abuse.
• Cosmetic Surgery other than:
• Reconstructive Surgery incidental to or following Surgery resulting from trauma, infection, or other diseases of the involved part; or
• Reconstructive Surgery because of a congenital disease or anomaly; and
• Manipulations of the musculoskeletal system, which includes manipulation of muscles, joints, soft tissue, bone, spine, as well as traction and massage, applications of heat or cold, except in Louisiana. (Except in Minnesota)
• Loss due to the Covered Person being legally intoxicated or under the influence of alcohol as defined by the jurisdiction in which an Accident occurs. (In Minnesota, the exclusion for Loss due to the Covered Person being legally intoxicated is defined by the alcohol level in excess of the state's legal intoxication limit – not the jurisdiction in which an accident occurs.)
• Loss due to the Covered Person voluntarily using any drug, narcotic or controlled substance, unless as prescribed by a Doctor; except in Connecticut.

DENTAL EXCLUSIONS

Benefits will not be paid for dental expenses arising from or in connection with:

• Services or supplies for which a charge is not customarily made in the absence of insurance.
• Injury arising out of or in the course of employment; or which is compensable (in South Dakota, which is paid) under any Worker's Compensation or Occupational Disease Act or Law.
• Declared or undeclared war, or act of war.
• A service furnished to a Covered Person for:
• Cosmetic purposes, unless needed as a result of Injury. Facing on crowns, or pontics, posterior to the second bicuspid shall always be considered cosmetic;
• Dental care of a congenital or developmental malformation (unless benefits for orthodontic services are specifically provided in the Schedule of Benefits).
• Replacement of lost or stolen appliances.
• Appliances, restorations, or procedures for the purpose of altering vertical dimension, restoring or maintaining occlusion, splinting, or replacing tooth structure lost as a result of abrasion or attrition, or treatment of disturbances of the temporomandibular joint. In Arkansas, treatment for the temporomandibular joint is not excluded.
• A service not furnished by a Dentist, except:
• That performed by a Dental Hygienist under the supervision of a Dentist;
• X-rays ordered by a Dentist.
• Any service furnished during the 30-day period starting on the date coverage becomes effective for a Covered Person, unless needed as a result of Injury. This limitation applies only to a Covered Person who must submit evidence of good health before coverage becomes effective. This exclusion does not apply to Maryland residents.

NOTE: Not all of our products are available in all states where we are licensed. Policies' exclusions apply. Availability, Features, Benefits and Options may vary by state. This is a limited-benefit policy and is not a substitute for a major medical plan.

This website is for illustrative purposes only. It is not a contract of insurance. It is intended to provide a general overview of the HealthAssist and HealthAssure insurance coverages. Please remember only the insurance policy can give actual terms of coverage. All benefits payable are subject to the definitions, limits, maximums, deductibles, benefit periods and limitations and exclusions of the policy. The underwriting company reserves the right to increase rates at renewal. The medical and dental insurance plans are underwritten by The Chesapeake Life Insurance Company. Star HRG, PO Box 55270, Phoenix, AZ 85078-5270.