Exclusions
(1) Any expense which You are not legally obligated to pay.
(2) Services which are not Medically Necessary or are not furnished by and under supervision of a Physician.
(3) Expenses for services and supplies for which You are entitled to benefits, services or reimbursement through the VeteransâÃÂàAdministration, WorkersâÃÂàCompensation insurance, any private health plan or from any other source except Medicaid.
(4) Expenses in excess of UCR.
(5) Intentional self-inflicted injuries while sane or insane.
(6) Treatment for alcoholism, drug addiction, allergies, and/or Mental or Nervous Disorders and all related symptoms and side effects.
(7) Rest cures, quarantine or isolation.
(8) Cosmetic surgery unless necessitated by an accidental Injury.
(9) Dental exams, dental x-rays and general dental care except as a result of an accidental Injury.
(10) Eye glasses or eye examinations.
(11) Hearing aids or hearing examinations.
(12) General or routine examinations.
(13) Injuries sustained from participation in Hazardous Sports or Activities.*
(14) Pregnancy and pregnancy-related conditions including but not limited to fertility, pre-natal care, childbirth, miscarriage, abortion or postpartum conditions.
(15) Injuries or Illnesses due to War or any act of War whether declared or undeclared.*
(16) Injuries or Illnesses due to Terrorism or an Act of Terrorism whether declared or undeclared.
(17) Injuries or Illnesses due to an Act of Terrorism involving the use or release of any nuclear weapon or device or chemical or biological agent, regardless of any contributory cause(s).
(18) Injuries or Illnesses sustained while committing a criminal or felonious act.
(19) Expenses incurred for or resulting from pain which is not supported by medical diagnosis.
(20) Cataract surgery.
(21) Any elective surgery, including but not limited to complications of previous elective or cosmetic surgeries.
(22) Custodial Care.
(23) Expenses for supplies and services that were not incurred with in the specified Geographic Area.
(24) Pre-existing conditions.
* This exclusion can be removed if the appropriate additional premium has been paid and the optional benefit is indicated on the Schedule or attached by an endorsement.
