Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.9 Exclusions.

The following charges are excluded, are not Covered Charges, and will not be paid by the Plan:

1. Excess of Reasonable and Customary. Any portion of a charge that is in excess of the Reasonable and Customary charge for the treatment.
   
   
2. Not Medically Necessary. Any charge for treatment that the Plan determines is not Medically Necessary.
   
   
3. Experimental or Not Generally Accepted Treatment. Subject to the exceptions described in the definition of "Experimental or Not Generally Accepted," charges incurred for a treatment that is Experimental or not Generally Accepted.
   
   
4. No Legal Obligation to Pay. Charges for which a member is not legally obligated to pay, or treatment which he or she obtains, or is entitled to obtain, under any plan or program without charge, other than Medicaid or Medi-Cal. This will include charges for treatment which is provided or paid for by the federal government at a Veteran's Administration facility for (i) an Injury or Illness related to the patient's military service or (ii) the member or his or her Dependents, if retired from the armed services.
   
   
5. Non-Covered Individual. Charges incurred by someone other than a Covered Individual, even if living in the same household.
   
   
6. Third Party Responsible. Charges incurred for which a third party is responsible; provided, however, that benefits may be advanced by the Plan pending determination by way of court or administrative determination of third party liability or by way of settlement, whether or not the third party is responsible for payment of medical and Hospital costs. (See also Section 8.12.)
   
   
7. Act of War, Riot or Civil Disorder. Charges incurred as a result of an act of war (whether declared or not) and any related act, and charges incurred as the result of participation in a riot or civil disorder.
   
   
8. Alternative Reproduction Birth Methods. Charges incurred in connection with (i) artificial insemination, (ii) in vitro fertilization or (iii) in-vivo fertilization.
   
   
9. Certain Eye Surgery. Charges incurred for surgery to the eye to correct a refractive error (such as radial keratotomy) and charges incurred for the purchase or fitting of eye glasses or contact lens, but not including charges incurred for a contact lens or eye glasses and frames required immediately following, and as a result of, cataract surgery.
   
   
10. Cosmetic Charges. Charges incurred in connection with treatment that is cosmetic; other than (i) reconstructive surgery to restore tissue damaged by Injury or Illness (including surgery on one or both breasts to re-establish symmetry following a mastectomy) or (ii) treatment of a Child from birth to correct a congenital disease or anomaly, including an oral defect.
    
    
11. Custodial Care. Non-medical care that helps individuals with activities of daily living, preparation of special diets and self-administration of medication not requiring constant attention of medical personnel. Providers of custodial care are not required to undergo medical training.
    
    
12. Elective Abortion. Charges incurred for an elective abortion, except where the life or health of the mother is in danger if the procedure is not performed.
    
    
13. Hearing Aids. Charges for hearing aids.
    
    
14. Personal Comfort Items. Charges for personal comfort items used for an individual's personal comfort, such as air purifiers, humidifiers, whirlpools, Jacuzzi or hot tub devices, exercise equipment, reclining chairs, bed boards, or other equipment not primarily medical in nature.
    
    
15. Transportation. Charges for transportation, except professional ambulance services.
    
    
16. Vitamins, Dietary Supplements, Weight-Control, Beauty Aids. Charges for multiple and non-therapeutic vitamins, dietary supplements, weight-control items, and health and beauty aids.
    
    
17. Work-Related. Charges incurred as a result of (i) an Injury which arises out of or in the course of any employment with any other employer or (ii) an Illness for which the member or Dependent (a) is entitled to benefits under any workers' compensation law or occupational disease law or (b) receives any settlement from a workers' compensation or occupational disease carrier. (See also Section 8.12.)