Note: These exclusions are identical to the ones listed in the Benefit Summaries above.

 

Benefits shall not be provided in any of the following circumstances or for any of the following conditions under the terms of this Policy:

General Exclusions

• Any procedure, treatment, supply, or service not specifically listed as a Covered Service.
• Any situation in which no specific medical treatment plan or psychiatric plan is furnished, including but not limited to rest cure, detoxification setup, Custodial Care, etc.
• Charge for services and supplies: (1) for which an Insured is not required to make payment, (2) that are made only because benefits are available under this Policy, or (3) for which an Insured would have no legal obligation to pay in the absence of this or any similar coverage.
• Charges for telephone or internet consultations; missed appointments; claim form completion; interest charges; legal services; obtaining medical records; setup and delivery of Durable Medical Equipment; or Provider travel and/or lodging expenses.
• Any services, supplies, or charges which result from the treatment of any direct or indirect complication of any Illness or condition for which coverage is not or was not provided.

Causes of Injury and Illness

• Expenses for services incurred as a result of any work related Injury or Illness, including any claims that are resolved pursuant to a disputed claim. The only exception would be if the Insured is exempt from state or federal Workers’ Compensation Law. See the Right of Reimbursement and Subrogation section of these General Provisions.
• Any Injury or Illness resulting from any act of war or from explosion of atomic or similar fissionable materials in war (declared or undeclared) or any Illness or Injury contracted or incurred during military service, including any complications or recurrences thereof, or national disaster; participation in a felony, riot or insurrection.

Convenience Items/Services

Convenience items such as telephones; television; guest trays or meals; personal hygiene items or services; or homemaker or housekeeping services, except by home health aides as ordered in a hospice treatment plan.

Cosmetic/Reconstructive Surgery

Cosmetic and/or reconstructive services and supplies, including services and supplies related to a previous cosmetic procedure or complications of a previous cosmetic procedure, except as follows:

• Related to breast reconstruction following a mastectomy to the extent required by law (refer to the Women’s Health and Cancer Rights provision for additional information);
• Due to a trauma, infection, or other disease of the involved part; or
• Due to congenital disease or anomaly for an Insured Dependent child.
• For the purposes of this exclusion, cosmetic means a procedure that primarily improves or changes appearance and does not primarily restore an impaired function of the body.

Coverage by Others

• Benefits which are payable under any automobile medical, personal injury protection ("PIP"), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance is issued to or makes benefits available to the Insured, whether or not application is duly made therefore.
• To the extent benefits are provided or covered by any governmental agency, except as otherwise provided by law.

Equipment

• Physical fitness or Physical Therapy equipment, including but not limited to whirlpools, spas, hot tubs; weight lifting equipment; charges in or by health spas, and charges for weight reduction programs.
• Humidifiers; vaporizers; air conditioners; or any other air filtration or purification unit or system.
• Heating pads, contour chairs, and therapeutic beds (not including certified, standard model hospital beds which will be paid under the Durable Medical Equipment section).

Experimental or Investigational Services and Procedures

Investigative treatment as determined by Regence BSI pursuant to the Definitions section of these General Provisions.

Foot Care (Routine)

Routine foot care (including removal of corns or calluses or trimming of nails), foot impression casting including x-rays incidental to casting, orthopedic shoes, arch supports, and other supportive devices for the feet.

Hearing

Routine hearing examinations; hearing aids.

Hospitalization

Hospital benefits when hospitalization is primarily for diagnostic studies or Physical Therapy when such procedures could have been done adequately and safely on an Outpatient basis.

Immunizations

Immunizations required for travel abroad, including but not limited to cholera, plague, typhoid, typhus, and yellow fever.

Obesity or Weight Control

• Diet and weight monitoring and educational services.
• Special foods, diets, vitamins, minerals, dietary and nutritional supplements, and nutritional therapy.
• Any medical or surgical procedures primarily for treatment of obesity that are intended to result in weight reduction, or for reversal, revision, or complications of surgery for obesity.

Prescription Medications and Drugs

• Prescription drugs and medicines for smoking cessation.
• Drugs and supplies not requiring a prescription order, including but not limited to aspirin, antacid, benzyl peroxide preparations, cosmetics, medicated soaps, food supplements, syringes, and bandages; Antabuse, Methadone, Minoxidil, or Rogaine hair preparations; experimental drugs, including those labeled "Caution-limited by Federal Law to Investigational Use"; and prescription medication related to health care services which are not covered under this Policy. Notwithstanding this exclusion, Regence BSI may choose to cover certain over-the-counter medications when prescription drug benefits are provided under this Policy. Such approved over-the-counter medications must be identified by Regence BSI in writing and will specify the procedures for obtaining benefits for such approved over-the-counter medications. Please note that the fact a particular over-the-counter drug or medication is covered does not require Regence BSI to cover or otherwise pay or reimburse the Insured for any other over-the-counter drug or medication.
• Laetrile (amygdalin).

Providers

Expense for services furnished by a Provider who is related to the Insured by blood or marriage or who resides in the Insured's household.

Reproductive Services

• Pregnancy tests.
• Services and supplies for or in connection with: (1) infertility treatment, except to the extent Covered Services are required to diagnose such a condition, (2) reversal of sterilization; (3) surrogate pregnancy; (4) Assisted Reproductive Technology (ART) procedures; and (5) fertility drugs and medications (Pergonal, etc.).
• Elective abortions, except to preserve the life of the female Policyholder or spouse upon whom the abortion is performed.
• Maternity benefits for Dependent children.

Sex Transformation

Procedures related to sex transformations.

Temporomandibular Joint (TMJ) Disorders and Orthognathic Surgery

• Services and supplies related to dentistry, dental implants, orthodontic treatment, or oral surgery whether necessary due to an accident, disease, deformity, or dental treatment, except as provided in this Policy.
• Orthodontic bracing for treatment of Temporomandibular Joint (TMJ) Disorders.

Vision

• Visual therapy or training.
• Radial keratotomy (refractive keratoplasty or other surgical procedures to correct refractive errors/ astigmatism).

 

Note: These limitations are identical to the ones listed in the Benefit Summaries above.

 

General Limitation

Claims submitted to Regence BSI more than fifteen (15) months after the last day on which Covered Services were rendered shall be ineligible for payment, unless it can be shown to the satisfaction of Regence BSI that there was unusual and justifiable cause for such late submission.

Alternative Care

Total combined benefits paid for services of a Chiropractor, massage therapist, naturopath, or acupuncturist shall be limited to a combined maximum of $500 per Insured each calendar year.

Chemical Dependency

Total Inpatient and Outpatient benefits paid for the treatment of Chemical Dependency shall be limited to a combined maximum of $1,500 per Insured each calendar year.

Diabetic Education

Total benefits paid for diabetic education shall be limited to a maximum of $400 per Insured each calendar year when education services are provided through a Regence BSI-approved diabetic education program.

Home Health Care

Total benefits paid for home health care visits is limited to a maximum of $5,000 per Insured each calendar year.

Hospice Care

Total benefits paid for hospice care services shall be limited to $5,000 during an Insured's lifetime.

Human Growth Hormone Therapy

Total benefits paid for human growth hormone therapy shall be limited to a maximum of $25,000 per Insured each calendar year.

Mental Health Treatment

Total Inpatient and Outpatient benefits paid for the treatment of Mental or Neuropsychiatric Conditions shall be limited to a combined maximum of $1,500 per Insured each calendar year.

Prescription Medications

Total benefits paid for brand name prescription drugs and brand name mail-order maintenance drugs shall be limited to a combined maximum of $2,000 per Insured each calendar year.

Skilled Nursing Facility

Total benefits paid for extended care in a skilled nursing facility shall be limited to a maximum of thirty (30) days per Insured each calendar year.

Temporomandibular Joint (TMJ) Disorders and Orthognathic Surgery

Total benefits paid for the treatment of Temporomandibular Joint (TMJ) Disorders and orthognathic conditions shall be limited to a maximum of $2,000 during an Insured's lifetime.

Therapies

• Total Outpatient benefits paid for Physical Therapy shall be limited to a maximum of $800 per Insured each calendar year.
• Total Outpatient benefits paid for Speech Therapy shall be limited to a maximum of $800 per Insured each calendar year.
• Total Outpatient benefits paid for Occupational Therapy shall be limited to a maximum of $800 per Insured each calendar year.
• Total Outpatient benefits paid for Respiratory Therapy shall be limited to a maximum of $800 per Insured each calendar year.

Transplants

Total benefits paid for covered human organ and tissue transplant and bone marrow reinfusion services shall be limited to a maximum of $250,000 during an Insured's lifetime.

Vision

• Total benefits paid for routine eye examinations shall be limited a maximum of one (1) examination per Insured each calendar year.
• Total benefits paid for vision hardware, including frames, lenses and contacts shall be limited to a combined maximum of $100 per Insured each calendar year.