Fundamental Care>Why Fundamental Care>Limitations & Exclusions

Limitations for Pre-Existing Conditions

PRE-EXISTING DEFINITION
A condition for which a Covered Person has been medically diagnosed, treated by, or sought advice from, or consulted with, a Physician during the 6 months before he/she became insured is a Pre-Existing Condition.

LIMITATION FOR PRE-EXISTING CONDITION 1.
Benefits for this coverage shall not be payable for a Pre-Existing Condition. A condition for which a Covered Person has been medically diagnosed, treated by, or sought advice from, or consulted with, a Physician during the 6 months before he became insured is a Pre-Existing Condition. This provision will cease to apply to any expenses incurred in connection with a Pre-Existing Condition after the earliest of:

1.   The end of a continuous period of 6 months of coverage, the final day of which must occur after the Covered Person's effective date of insurance, during which:

      a.   No expense is incurred;

      b.   No diagnosis or treatment or advice is received; and

      c.   A Physician is not consulted; as the result of the Pre-Existing condition or any related condition;

2.   12 months of continuous coverage.

The Pre-Existing Condition Limitation above does not apply to newborn or adopted children, nor to any pregnancy. Any Pre-Existing Condition limitation can be reduced by that period of time the Covered Person was previously insured for the condition causing claim; provided such Covered Person:

1. Was validly insured under his prior plan with Creditable Coverage, immediately prior to becoming insured under this policy; and

2. Became insured under this policy within 63 days after termination of his prior coverage.

BENEFIT LIMITATIONS 1.
Coverage is not provided for services, supplies or equipment for which a charge is not customarily made in the absence of insurance. No coverage is provided for loss caused by or resulting from:

1. Any Injury or Sickness arising out of, or in the course of, employment for wage or profit, provided the Covered Person is covered under any Worker's Compensation Act, Occupational Disease Act, or similar act or law, unless the Covered Person is self-employed;

2. Declared or undeclared war; or act of war;

3. Expenses which are not ordered or under the written direction of a Physician;

4. Cosmetic surgery. This does not apply to:

            a. Reconstructive surgery incidental to or following surgery resulting from trauma, infection, or other diseases of the involved part; or

            b. Reconstructive surgery because of a congenital disease or anomaly of a covered Dependent newborn or adopted infant; or

            c. Reconstructive surgery on a non-diseased breast to restore and achieve symmetry between two breasts following a mastectomy.

5. Hearing examinations or hearing aids;

6. Vision services and supplies related to eye refractions or eye examinations, eyeglasses or contact lenses or prescriptions or fitting of eyeglasses other than for a disease process, and radial keratotomy, keratomileusis or excimer laser photo refractive keratectomy or similar type procedures or services;

7. Charges made by a health care provider if such provider is a member of the Covered Person's Immediate Family or is living with the Covered Person;

8. Any period of Custodial Care confinement in a Hospital or Skilled Nursing Facility;

9. Charges for Home Health Care Services, unless provided in lieu of a Hospital confinement.

10. The Covered Person’s commission of a felony;

11. Charges in connection with manipulations of the musculoskeletal system;

12. The treatment of mental or nervous disorders, alcoholism, or any form of substance abuse, except as specifically provided;

13. Intentionally self-inflicted Injury or suicide attempt while sane or insane;

14. Dental care and treatment, except that required by Injury and rendered within 6 months of the Injury;

15. Treatment which is determined to be Experimental or Investigational.

16. Treatment which is not considered Necessary Treatment.

17. Treatment, services or supplies provided outside of the United States, except for the Necessary Treatment of an Emergency.

18. Treatment received in an Emergency Room or Urgent Care Facility if not an Emergency.

19. An overdose of drugs, being intoxicated or under the influence of intoxicants, hallucinogens, narcotics or other drugs, directly or indirectly, unless taken as prescribed by a Physician;

20. Any drug, treatment or procedure that either promotes or prevents conception or prevents childbirth, including but not limited to: (a) artificial insemination; (b) in-vitro fertilization    or other treatment for infertility; (c) treatment for impotency; (d) sterilization or reversal of sterilization; or (e) abortion (unless the life of the mother would be endangered if the fetus were carried to term), unless otherwise stated herein;

21. Weight loss or modification, or complications arising therefrom, or procedures resulting therefrom or for surgical treatment of obesity including but not limited to gastric by-pass, wiring of the teeth and all forms of Surgery performed for the purpose of weight loss or modification or the reversal/modification of such procedure;

22. Breast reduction or augmentation unless necessary in connection with breast reconstructive Surgery following a mastectomy performed while insured under the Policy;

23. Modification of the physical body in order to improve the psychological, mental or emotional well-being of the Covered Person, such as but not limited to sex-change Surgery;

24. Marriage, family, or child counseling for the treatment of premarital, marriage, family or child relationship dysfunctions;

25. Directly or indirectly engaging in an illegal occupation or illegal activity;

26. Care in a nursing home, custodial institution or domiciliary care or rest cures;

27. Preparation and presentation of medical reports for appearance at trials or hearings. Physical examinations required for school events, camp, employment, licensing and insurance are expressly excluded;

28. Immunizations required for the sole purpose of travel outside of the United States;

29. Payment for care for military service connected disabilities for which the Covered Person is legally entitled to services and for which facilities are reasonably available to the Covered Person and payment for care for conditions that state or local law requires be treated in a public facility;

30. Personal comfort items, such as television, telephone, lotions, shampoos, etc.;

31. Physical, Occupational, and Speech Therapy not prescribed by a Physician or not received within 60 days following related Hospital confinement or Surgery.

No benefits will be paid for any expense incurred after the date the policy terminates.

TERMINATION – The earliest of:

1. The date ending the last period for which You made any required premium contribution;

2. The date You enter the armed forces of any country; membership in the reserves is not deemed entry into the armed forces;

3. The date You are no longer a member of a class eligible for insurance; is the date on which Your insurance will terminate.

The insurance of all Covered Persons will terminate immediately:

1. With respect to a coverage, on the date on which that coverage is canceled;

2. On the date of termination of the policy. Termination of participation with the Holder by an Employer shall be deemed termination of the policy with respect to such Employer.

The insurance of a covered Dependent will terminate on the earliest of:

1. The date Your insurance terminates;

2. The date he enters the armed forces of any country; membership in the reserves is not deemed entry into the armed forces; or

3. The date he ceases to be a Dependent as defined.

However, if an unmarried insured Dependent child is:

1. Incapable of self-support due to mental retardation or physical handicap; and

2. Dependent upon You for support and maintenance;

This insurance will not be terminated because of age. We will require due proof of the child’s incapacity within 31 days after he reaches the termination age for children.

The insurance for the child may be continued for as long as:

1. The incapacity and dependency continues; and

2. The insurance remains in force for the Insured Person.

Dependent eligibility
Your eligible dependents are your spouse and your unmarried dependent children under 19 years of age (if in TX, 25 years of age). The age limit is through 25 if the child is enrolled full-time in an accredited school or college. Your dependent information will be specified after you enroll and have received your summary plan description booklet.

Definition of Dependent 1.

“Dependent” means:

1. Your spouse;

2. Unmarried children who are under 19 years of age; and

3. Unmarried children who are 19 years of age through 25 years of age if the child:

a. Is attending an accredited school full-time; and

b. Is financially dependent upon You for support.

FOOTNOTES

This provision or limitation varies by state.
Check availability - not yet available in all states.

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Fundamental Care>Why Fundamental Care>Limitations & Exclusions

Limitations for Pre-Existing Conditions