What Is Not Covered

In addition to the various exclusions and limitations set forth in your Summary Plan Description (SPD), the Benefit Fund does not cover the following charges:

  • Charges in excess of the Benefit Fund’s Schedule of Allowances
  • Charges for services provided and supplies or appliances used before you, your spouse or your children became eligible for Benefit Fund coverage
  • Charges for services covered under any mandatory automobile or no-fault policy
  • Charges associated with any work-related accidental injuries or diseases that are covered under Workers’ Compensation or comparable law
  • Charges for care resulting from an act of war
  • To the extent permitted by law, charges related to an illness or accident/injury that was deliberately self-inflicted except where such illness or accident/injury is attributable to a mental condition or that resulted from the person committing an illegal act
  • Charges for services or materials that do not meet the Benefit Fund’s standards of professionally recognized quality
  • Charges that would not have been made if no coverage existed or charges that neither you nor any of your dependents are required to pay. For example, the Benefit Fund will not pay for services provided by members of your or your dependent’s immediate family
  • Charges made by your provider for broken appointments
  • Charges for in-hospital services that can be performed on an ambulatory or outpatient basis
  • Charges for procedures, treatments, services, supplies or drugs for cosmetic purposes, except to remedy a condition that results from an accidental injury that occurred while covered by the Benefit Fund
  • Charges for experimental or unproven procedures, services, treatments, supplies, devices, drugs, (see definition of “Experimental” in Section IX)
  • Charges for services, treatments and supplies covered under any other insurance coverage or plan, or under a plan or law of any government agency or program, unless there is a legal obligation to pay
  • Charges for services that are not FDA approved for a particular condition
  • Charges that are unreasonable, excessive or that are beyond a provider’s normal billing rate or beyond his or her scope or specialty
  • Charges for services that are not covered by the Benefit Fund, even if the service is Medically Necessary
  • Charges for services that are not Medically Necessary (see Section C)
  • Charges related to interest, late charges, finance charges, court or other costs
  • Charges related to programs for smoking cessation, weight reduction, stress management and other similar programs that are not provided by a licensed medical physician or not Medically Necessary
  • Charges for infertility treatment, including, but not limited to, in vitro fertilization, artificial insemination, embryo storage, cryosterilization and reversal of sterilization
  • Charges for claims submitted more than 12 months after the date of service
  • Charges related to an illness or accident/injury resulting from the conduct of another person, where payment for those charges is the legal responsibility of another person, firm, corporation, insurance company, payer, uninsured motorist fund, no-fault insurance carrier or other entity
  • Charges for services that are custodial in nature
  • Charges for services in excess of or not in compliance with the Benefit Fund’s guidelines, policies or procedures
  • Charges that are not itemized
  • Charges for over-the-counter, personal, comfort or convenience items such as bandages or heating pads (even if your physician recommends them)
  • Charges for services which are not pre-approved in accordance with the terms of the Plan
  • Charges for claims containing misrepresentations or false, incomplete or misleading information
  • Charges for invalid and/or obsolete CPT or HCPCS codes
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