Covered Expenses* are as follows:
Covered expenses are charges for services or supplies prescribed by a physician for treatment of an illness or injury covered by your policy. The charges must be incurred for medically necessary care while the policy is in effect. A covered expense is incurred on the date a service is rendered or received and may not exceed the usual and customary or reasonable charge as defined by the policy. Subject to the exclusions, limitations and conditions described in the policy, the following services and supplies will be considered covered expenses:
- Hospital room, board, and general nursing care, limited to the hospital’s average semi-private room charge, unless confined in a coronary or intensive care unit.
- Other hospital services including emergency room, outpatient and ambulatory surgical center charges.
- Skilled nursing facility room, board, and general nursing care, limited to the facility’s average semi-private room charge, up to a maximum of 100 days, (other limitations apply; see your policy for complete description of benefit). Benefits for care in a Skilled Nursing Facility are not provided for treatment of mental disorders.
- Physician services for diagnosis, treatment, and surgery.
- X-rays, radioactive treatment, and laboratory tests.
- Breast and pelvic exams, mammograms, and Pap smear exams (if such exams are related to an annual women’s examination).
- Prostate cancer screening exams.
- Colorectal cancer screening exams.
- Anesthesia and oxygen and their administration.
- Private nursing care by R.N. or L.P.N. in the home (limitations apply). Services are not covered for mental disorders.
- Licensed ambulance service, limited to two trips per illness or injury (other limitations apply; see your policy for complete description of benefit).
- Physical, occupational, speech and audiological therapy, up to 30 sessions (other limitations apply).
- Home health care (up to 40 visits) when prescribed by a physician and rendered by a licensed home health agency (see your policy for complete description of benefit). Home Health Care will not be covered for mental disorders.
- Rental (up to purchase price) of wheel chair, hospital type bed, or other durable medical equipment unique to medical care or treatment.
- Prosthetic and Orthotic Devices that are medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that are not solely for comfort or convenience.
- Blood and blood products, administration of blood, and blood processing.
- Organ transplants, including heart, kidney, liver and bone marrow transplants, up to a maximum of $250,000 (other limitations apply; see your policy for complete description of benefit).
- Kidney disease.
- AIDS, including AIDS, AIDS Related Complex (ARC) or related immuno deficiency disorders.
- Casts, splints, crutches, orthopedic braces, colostomy bags, catheters, syringes, dressings, and initial contact lens following cataract surgery performed while covered under the policy.
- Mental health services for medically necessary outpatient and inpatient treatment of mental disorders (see your policy for complete description).
- Diabetes services and supplies incurred for persons diagnosed as having insulin using diabetes, noninsulin using diabetes or elevated blood glucose levels induced by pregnancy (see your policy for complete description of benefit).
- Cosmetic surgery as follows:
- Cosmetic surgery necessary as a direct result of an Injury sustained while this Policy is in effect; or
- Charges in connection with congenital defect of a child born while this Policy is in effect; or
- Reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the breast on which the mastectomy was not performed to produce symmetrical appearance, and prosthesis and physical complications with regard to all stages of mastectomy, including lymphedemas.
- Drugs which require the written prescription of a physician (pre-existing limitations and deductibles apply).
- Non-prescription elemental enteral formula for home use if the formula is medically necessary for the treatment of severe intestinal malabsorption (see your policy for complete description of benefit).
Extension of Benefits While Hospitalized
If a member is confined to a hospital on the expiration date of this policy, that member’s coverage under the policy will continue without payment of additional premium.
Coverage will continue:
1. Until the date the member is discharged from the hospital; or
2. Until the date on which the applicable benefit maximums are reached, whichever occurs first.
Limited Pregnancy Benefit
Covered expenses with respect to the pregnancy benefit are limited to services and supplies that are:
- Provided in direct connection with the treatment of an involuntary complication of pregnancy. The term “involuntary complication of pregnancy” includes, but is not limited to:
- toxemia of pregnancy;
- ectopic pregnancy;
- nephritis or pyelitis of pregnancy;
- puerperal infection;
- surgery due to spontaneous termination of pregnancy (miscarriage or missed abortion); or
- non-elective cesarean section. All other charges made in connection with pregnancy or childbirth are excluded; and
- Incurred while the member is insured under the policy.
Limited Alcoholism Benefit
The policy will consider services rendered by a facility or other provider licensed to treat alcoholism as covered expenses. Benefits for treatment of alcoholism are limited to a maximum of $4,500 during the policy term.
The policy does not cover:
- Pre-existing conditions (see the definition below in the section titled “Pre-Existing Conditions”).
- Illness or injury incurred in the course of any employment for wage or profit or for which benefits are available under Workers’ Compensation or similar law.
- Illness or injury covered by Medicare.
- Hospital confinement for medical observation or diagnostic exams.
- Eye refractions and eyeglasses.
- Well baby care.
- Hearing tests and hearing aids.
- Routine physical exams, tests or screening procedures (certain exceptions apply).
- Treatment of drug abuse or drug addiction.
- Organ transplants not specifically provided in the section of your policy titled “Covered Expenses” and any resulting complications.
- Treatment of intentional self-inflicted injury.
- Elective sterilization, family planning, birth control drugs or devices, artificial insemination, in vitro fertilization, diagnosis or treatment of infertility, reversal of sterilization, or genetic testing or counseling.
- Cosmetic surgery not specifically provided in the section titled “Covered Expenses”, including the removal of any health tissue or organs, and any resulting complications.
- Services or supplies not reasonably intended for treatment of illness or injury or which are not medically necessary (as defined in your policy).
- Acupuncture, massage, or massage therapy.
- Private duty nursing for hospital or skilled nursing facility inpatients.
- Substance related disorders; life transition problems; emotional or nervous disorders or counseling for these conditions; treatment of learning disorders or disabilities; or skilled nursing facility services, home health care, residential treatment and custodial care for any mental disorder. Court ordered treatment will not be covered unless LifeMap Assurance Company’s medical director or designee determines the treatment to be medically necessary.
- Any condition caused by or arising out of service in the armed forces of any country, or from war or any act of war, or from participation in a felony, riot, or insurrection.
- Sexual dysfunction or inadequacy procedures and any resulting complications.
- Services provided by an immediate family member.
- Treatment for obesity or weight control, including surgery and any resulting complications.
- Charges incurred after your policy ends, except as stated in your policy (see section titled “Extension of Benefits While Hospitalized” for brief description).
- Charges which exceed usual and customary or reasonable (as defined in your policy).
- Services rendered by governmental agencies or facilities, except as provided by law.
- Dental exams, treatment, or orthodontics.
- Services or supplies to change the position of the bone of the upper or lower jaw (certain exceptions apply).
- Services or supplies that are experimental or investigational (see your policy for complete details).
- Confinement in a health facility for custodial or maintenance care, rest, or to change a patient’s environment.
- Pregnancy or childbirth, except complications of pregnancy as stated in your policy (see section titled “Limited Pregnancy Benefit” for brief description).
- Treatment of alcoholism, except as stated in your policy (see section titled “Limited Alcoholism Benefit” for brief description).
- Charges which are reimbursed due to third party liability or motor vehicle coverage (see your policy for complete details).
There is no coverage for pre-existing conditions under this Policy. Pre-existing condition means an illness or injury for which a Member, during the 5 year period immediately preceding the Effective Date of the Policy:
- Received a medical diagnosis of the condition; or
- Received medical care for a documented suspicion of the condition.
A condition is also considered to be pre-existing if, during the 5 year period immediately preceding the Effective Date of the Policy, significant and obvious symptoms existed which would cause a prudent person to seek diagnosis, advice, care, or treatment.
ABOUT THIS WEB SITE
This web site provides a brief description of the important features of this plan. This is not the insurance contract. The actual plan sets forth in detail the rights and obligations of both you and your insurance company. State mandated benefits, if applicable, are incorporated through a rider attached to your plan.