GENERAL BENEFIT EXCLUSIONS AND LIMITATIONS
Important Note Regarding Relationship Between the Fund and Health Care
Providers:
No health care provider is an agent or representative of the Fund. The Fund
does not control or direct the provision of health care services and/or supplies
to Fund members or their covered dependents by anyone. The Fund makes no
representation or guarantee of any kind concerning the quality of health care
services or supplies furnished by any provider. The foregoing statement applies
to any and all health care providers, including both preferred and non-preferred
providers under the terms of the Plan of Benefits. The statement also applies to
all entities (their agents, representatives and employees) which contract with
the Fund to offer preferred provider networks or other health-related supplies
to Fund members and their covered dependents. Nothing in this Plan affects the
ability of a health care provider to disclose alternative treatment options to a
Fund member or covered dependent. Although subject to benefit allowances and
limitations in the Plan with regard to payment, the choice of a provider and/or
treatment remains with the patient.
In addition to the
exclusions provided elsewhere in this Booklet or the exclusions set forth in
either the respective Personal Choice or Keystone HMO booklets (depending upon
the program in which the Member is enrolled), benefits are not payable for the
following:
1.
Charges arising from, or occurring in the course of, any gainful
occupation or employment. This exclusion applies regardless of whether a claim
is actually made or filed under any applicable workers’ compensation statute or
program.
2.
Charges for services or supplies which are not Medically Necessary or
Medically Appropriate as determined by the Fund, its Claims Administrator and/or
its Medical Consultant.
3.
Charges for treatments or procedures that are experimental or
investigative.
4.
Charges for treatments which are not approved by the attending physician.
5.
Charges which are not Usual, Customary and Reasonable.
6.
Charges in excess of the payment the provider of service accepted as
payment in full from any other source.
7.
Charges for custodial care or for maintenance of chronic conditions.
8.
Charges for services rendered by a member of the patient’s immediate
family (including in-laws).
9.
Charges that are made only because this coverage exists, or charges that
no covered individual is legally obligated to pay.
10.
Charges for treatments, services and/or supplies provided, ordered or
required by the United States government, or any other government (including
court-ordered treatment).
11.
Charges resulting from war or service connected injuries or diseases.
12.
Charges associated with any treatment for weight reduction.
13.
Charges for hearing aids or the examination and fitting of hearing aids.
14.
Charges to the extent that they are recovered from any person or
organization other than an insurer of the patient.
15.
Charges for cosmetic treatment and/or surgery for purposes other than
breast reconstruction following a mastectomy, correction of damages caused by
accidental injury, or for correction of a birth defect, providing that the
patient was covered under this Plan on the date of the accident or date of birth
and is still eligible as of the date of the cosmetic treatment or surgery. NOTE:
SURGERY GENERALLY CONSIDERED COSMETIC IN NATURE (EVEN THOUGH FOR MEDICAL
REASONS) REQUIRES PRIOR APPROVAL FROM THE FUND.
16.
Charges for the diagnosis and treatment of dislocations, strains, sprains
or misplacements of the skeletal structure (pertaining to the skeleton) or
musculature (the system of muscles), except for the first fifteen (15) visits
with a physician in any calendar year or when requiring the administration of a
general anesthesia, an opening or cutting operation, or confinement in a
hospital.
17.
Charges for orthotic shoe inserts (unless specifically covered under your
Summary of Benefits Schedule).
18.
Charges for immunizations and vaccines (unless specifically covered under
either the Personal ChoiceÔ
or Keystone HMOÔ
Programs)
19.
Charges for eye exercises, psychological testing, and learning
disabilities, school or DOT physicals.
20.
Charges for Counseling (including marriage counseling) or group therapy.
See definition of these terms in the following section for some exceptions.
21.
Charges for treatment of temporomandibular joint dysfunction in excess of
any coverage under the Fund's Dental Benefit Plan.
22.
Charges for sex change operations.
23.
Charges for penile prosthetic devices.
24.
Charges for the surgical correction of myopia.
25.
Charges for treatment of infertility, including, but not limited to,
in-vitro fertilization, artificial insemination, gamete intra-fallopian transfer
(GIFT), zygote intra-fallopian transfer (ZIFT) and/or reversal of a
sterilization procedure.
26.
Charges for any other medical, dental, vision, or pharmacy service except
as provided in your appropriate Summary of Benefits Schedule.
27.
Also, benefits will only be paid in accordance with provisions of the
Fund's various Plans. For example, Vision Care is provided for under its Vision
Care Plan and will not be provided under any other provision of the Plan unless
specifically included in such other Plan provision.
Health
& We
lfare
and Pension Funds