Plan year: August 18, 2008–August 17, 2009
Student Gold Health Insurance Plan
Exclusions and Limitations
The following list of exclusions is for descriptive purposes only. A complete list of exclusions can be found in the master policy.
No benefits will be paid for:
a) loss or expense caused by, contributed to, or resulting from;
or b) treatment, services or supplies for, at, or related to:
- Acupuncture — Expenses incurred for acupuncture, unless services are rendered for anesthetic purposes.
- Breast Surgery — Expenses incurred for breast reduction/mammoplasty.
- Breast Surgery — Expenses incurred for gynecomastia (male breasts).
- Chiropractice Care — Expenses incurred for chiropractic care (chiropractic coverage is available at Wardenburg Health Center only.)
- Cosmetic Surgery — Expenses incurred for plastic surgery, cosmetic surgery, reconstructive surgery, or other services and supplies that improve, alter or enhance appearance, whether or not for psychological or emotional reasons. This exclusion will not apply to the extent needed to:
- Improve the function of a part of the body that is not a tooth or structure that supports the teeth, and is malformed as a result of a severe birth defect (including harelip and webbed fingers or toes), or as direct result of disease, or surgery performed to treat a Sickness or Injury.
- Repair an Injury (including reconstructive surgery for prosthetic device for a Covered Person who has undergone a mastectomy) which occurs while the Covered Person is covered under the Plan. Surgery must be performed in the Policy Year of the Accident, which causes the Injury, or in the next Policy Year.
- Custodial Care — Expenses incurred for custodial care. Custodial care means services and supplies furnished to a person mainly to help him or her in the activities of daily life. This includes room and board and other institutional care. The person does not have to be disabled. Such services and supplies are custodial care without regard to: by whom they are prescribed, or by whom they are recommended, or by whom or by which they are performed.
- Dental Injury — Expenses incurred as a result of dental treatment; (except for treatment resulting from injury to sound; natural teeth).
- Educational Testing — Expenses incurred for, or related to, services, treatment, education testing, or training related to learning disabilities or developmental delays unless otherwise provided in the Policy (testing of ADD and ADHD is not covered; treatment is covered).
- Elective Treatment — Expenses incurred for elective treatment or elective surgery except as specifically provided elsewhere in this Policy and performed while this Policy is in effect.
- Experimental — Expenses incurred for or in connection with: procedures, services, or supplies that are, as determined by Aetna, to be experimental or investigational. A drug, a device, a procedure, or treatment will be determined to be experimental or investigational if:
- there are insufficient outcomes data available from controlled clinical trials published in the peer reviewed literature, to substantiate its safety and effectiveness, for the disease or Injury involved; or
- if required by the FDA, approval has not bee granted for marketing; or
- a recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational, or for research purposes; or
- the written protocol or protocols used by the treating facility, or the protocol or protocols of any other facility studying substantially the same drug, device, procedure, or treatment, or the written informed consent used by the treating facility, or by another facility studying the same drug, device, procedure, or treatment, states that it is experimental, investigational, or for research purposes.
- Family Member — Expenses incurred for any services rendered by a family member of a Covered Person’s immediate family or a person who lives in the Covered Person’s home.
- Felony — Expenses incurred as a result of commission of a felony.
- Governmental Hospital — Expenses incurred for treatment provided in a governmental hospital unless there is a legal obligation to pay such charges in the absence of insurance.
- Infertility — Expenses for the charges for, or related to, artificial insemination, in vitro fertilization or embryo transfer procedures, elective sterilization or its reversal, or elective abortion unless otherwise provided in the Policy (Testing of infertility is covered; treatment is not covered).
- Judgment/Settlement — Expenses for treatment of Injury or Sickness to the extent payment is made, as a judgment or settlement, by any person deemed responsible for the Injury or Sickness (or their insurers).
- Medically Necessary — Expenses incurred for a treatment, service, or supply which is not medically necessary, as determined by Aetna, for the diagnosis, care, or treatment of the Sickness or Injury involved. This applies even if they are prescribed, recommended, or approved by the person’s attending Physician, or dentist.
- No Charge — Expenses incurred for services normally provided without charge by the Policyholder’s Health Service, infirmary, or hospital, or by health care providers employed by the Policyholder.
- Organ Transplant — Expenses incurred for the removal of an organ from a covered person for the purpose of donating or selling the organ to any person or organization.
- Reasonable Charge — Expenses for charges that are not reasonable charges, as determined by Aetna.
- Riot — Expenses incurred as a result of Injury due to participation in a riot. “Participation in a riot” means taking part in a riot in any way; including inciting the riot or conspiring to incite it. It does not include actions taken in self defense; so long as they are not taken against persons who are trying to restore law and order.
- Routine Services — Expenses incurred for routine vision exams, routine dental exams, or other preventive services and supplies, except to the extent coverage for such exams, services or supplies is specifically provided in the Policy (vision exams are covered at Wardenburg Health Center only).
- Sexual Reassignment Surgery — Expenses incurred for, or related to, sex change surgery or to any treatment of gender identity disorders. (Please note that outpatient mental health counseling and prescribed drugs, including hormones (subject to the Plan provisions applicable to the Prescription Drug plan) are considered to be Covered Medical Expenses).
- Sports Injuries — Expenses incurred for Injury resulting from the play or practice of collegiate or intercollegiate sports; including collegiate or intercollegiate club sports (Intramurals are covered).
- Termination — Expenses incurred after the date insurance terminates for a Covered Person except as may be specifically provided in the Extension of Benefits Provision.
- Training — Expense for treatment of covered students who specialize in the mental health care field, and who receive treatment as part of their training in that field.
- Weight Loss — Expenses incurred for gastric bypass and any restrictive procedures for weight loss. Expense for services or supplies provided for the treatment of obesity and/or weight control (Treatment of morbid obesity is covered).
- Worker’s Compensation — Expenses incurred as a result of an Injury or Sickness for which benefits are payable under any Worker’s Compensation or Occupational Disease Law.
Any exclusion listed will not apply to the extent that coverage is required under any law that applies to the coverage.
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