Componentes

Benefits are not provided under any provision of this Plan for the following conditions, services, or supplies:

1. Any Injury or Illness that results from or arises out of any past or present employment or occupation for compensation or profit, including Illnesses and Injuries arising out of or occurring during the course of employment, even if the Covered Person fails to make timely application for or waives his right to those benefits. This includes benefits from occupational insurance purchased by an Employer, benefits provided under state or federal worker's compensation acts, employer liability laws, or other laws providing compensation for work- incurred Illnesses or Injuries.

2. Any expense in excess of the Usual, Customary and

Reasonable Charge.

3. Any expense or charge for services or supplies not

medically necessary or not recommended by a Physician. 4. Any expense incurred after eligibility terminates, except as

specifically provided.

5. Any loss, expense or charge which results from:

a. An intentionally self-inflicted Injury or Illness, unless such Injury or Illness is the result of a physical or mental health condition.

b. Suicide or attempted suicide, unless such suicide or

attempted suicide is the result of a physical or mental health condition.

6. Any loss, expense or charge resulting from the person's

participation in a riot or in the commission of a felony.

7. Any expense or charge which the person has no obligation

to pay or charges that are made only because the Plan exists.

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9. Any loss, expense or charge that results from cosmetic or reconstructive surgery, except:

a. For Injuries or Illness.

b. For repair of congenital defects of newborn children. c. For repair of defects resulting from surgery.

d. For the reconstruction of a breast after a mastectomy, including all stages of any reconstructive breast reduction performed on the non-diseased breast to make it equal in size with the reconstructed diseased breast.

10.Any loss, expense or charge which results from appetite

control or any treatment of obesity, including surgery and its complications, inpatient eating disorder programs, services and supplies connected with weight loss or weight control, even if the obesity is affected by psychological factors (except for anorexia nervosa and bulimia which are covered under the mental health benefit). This exclusion applies even if there is an Illness or Injury which may be helped by weight loss.

11.Any expense or charge for orthopedic shoes, orthotics, or other supportive devices for the feet.

12.Any expense or charge in connection with dental work or

dental surgery, unless specifically provided, including: a. Treatment involving any tooth structure, alveolar

process, abscess, or disease of the periodontal or gingival tissue.

b. Surgery or splinting to adjust dental occlusion.

13.Any expense or charge for treatment of craniomandibular

or temporomandibular joint (TMJ) disorders, except as specifically provided.

14.Any loss, expense or charge for the promotion of fertility including (but not limited to):

a. Fertility tests, drugs, supplies or devices. b. Reversal of surgical sterilization.

c. Any attempts to cause pregnancy by hormone therapy, artificial insemination, in vitro fertilization and embryo transfer or any similar treatment or method.

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15. Any services or supplies received in connection with a

Participant or Covered Dependent acting as a Surrogate

Mother, regardless of whether a Participant or Covered Dependent is a biological parent.

16.Any loss or charge for sex transformations or any treatment related to sexual dysfunction.

17.Chelation therapy, except for acute arsenic, gold, mercury or lead poisoning.

18.Any expense or charge for services or supplies which are: a. Not provided in accord with generally accepted

professional medical standards. b. For Experimental treatment.

c. Investigative, and not proven safe and effective.

19.Any expense or charge for services or supplies which are chiefly for instruction, education or training, except as specifically provided for diabetic self-management.

20.Any expense or charge for services or supplies that are

provided or paid for by federal government or its agencies; except for

a. The Veterans Administration, when services are provided to a veteran for a disability that is not service connected.

b. A military Hospital or facility, when services are provided to a Retired Participant (or dependent of a Retired Participant) from the armed services.

c. A group health plan established by a government for its own civilian employees and their dependents.

21.Any loss, expense or charges that result from an act of

declared or undeclared war or armed aggression. 22.Any loss, expense, or charge:

a. Which is incurred while on active duty or training in the Armed forces, National Guard or Reserves of any state or county; and

b. For which any governmental body or its agencies are liable.

23.Any expense or charge for Injuries or Illness caused by the act or omission of another person (known as a third-party)

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for which there is a potential opportunity to recover from the third-party, the third-party’s insurer or any liability policy. Benefits may be advanced by the Plan pursuant to the reimbursement provisions.

24.If you or your Covered Dependents are entitled to Medicare due to age, disability or as a result of End Stage Renal Disease (ESRD) and you or your Covered Dependent fails to enroll in Medicare when eligible, benefits are paid by the Plan as if the Participant or Covered Dependent is enrolled in Medicare. This exclusion applies regardless of whether you participate in the Plan as an Active, Associate, Retired, COBRA or self-pay eligible Participant.

25.Services provided by an acupuncturist, licensed naturopath or massage therapist, except as specifically provided in the Alternative Care Benefit.

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