Plan year: August 18, 2007–August 17, 2008

Student Gold Health Insurance Plan

Exclusions and Limitations

• What services outside of Wardenburg Health Center are not covered by Student Gold Health Insurance Plan?

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:

1. Acupuncture;
2. Addiction, such as nicotine addiction;
3. Air transportation;
4. Autistic disease of childhood, hyperkinetic syndromes, milieu therapy, learning disabilities, attention deficit disorder testing (treatment is covered) and attention deficit hyper activity disorder testing (treatment is covered), behavioral problems, parent-child problems, conceptual handicap, developmental delay or disorder or mental retardation, except as specifically provided in the policy;
5. Cosmetic procedures, except cosmetic surgery required to correct an Injury for which benefits are otherwise payable under this policy;
6. Dental treatment, except for accidental injury to sound, natural teeth. Injury as a result of chewing or biting will not be considered an accident or injury;
7. Elective surgery or elective treatment;
8. Elective abortion;
9. Eye examinations, eye refractions, eyeglasses, contact lenses, prescriptions or fitting of eyeglasses or contact lenses, vision correction surgery, or other treatment for visual defects and problems; except when due to a disease process;
10. Immunizations, except as specifically provided in the policy; preventive medicines or vaccines, except where required for treatment of a covered Injury;
11. Inpatient convenience items such as guest meals, telephones, televisions, etc.;
12. Injury or sickness for which benefits are paid or payable under any workers' compensation or occupational disease law or act, or similar legislation;
13. Injury sustained while (a) participating in any interscholastic, club, intercollegiate, or professional sport, contest or competition; (b) traveling to or from such sport, contest or competition as a participant; or (c) while participating in any practice or conditioning program for such sport, contest or competition;
14. Medical or non-medical self-care or self-help training and occupational therapy, recreation therapy, educational therapy, dance therapy, art therapy, except as described in the master policy;
15. Non-medically necessary maintenance care expenses. Example: physical therapy or chiropractic maintenance care as opposed to treatment of a condition. Maintenance care means treatment which is administered after the patient's status remains the same and no further improvement is expected; remaining symptoms are considered residual; it is indicated by infrequent, sporadic treatment (i.e., once a month or every other week);
16. Organ transplants, including organ donation;
17. Participation in a riot or civil disorder; commission of or attempt to commit a felony; or fighting;
18. Prescription drugs, services or supplies as follows:
    1. Therapeutic devices or appliances, including: hypodermic needles, syringes, support garments and other nonmedical substances, regardless of intended use; except as provided under Benefits for Diabetes;
    2. Immunization agents, biological sera, blood or blood products administered on an outpatient basis;
    3. Drugs labeled, "Caution—limited by federal law to investigational use" or experimental drugs;
    4. Products used for cosmetic purposes;
    5. Drugs used to treat or cure baldness; anabolic steroids used for body building;
    6. Anorectics—drugs used for the purpose of weight control;
    7. Fertility agents or sexual enhancement drugs, such as Parlodel, Pergonal, Clomid, Profasi, Metrodin, Serophene, or Viagra;
    8. Growth hormones; or
    9. Refills in excess of the number specified or dispensed after one (1) year of date of the prescription.
19. Reproductive/infertility services including but not limited to: family planning; infertility (male or female), including any services or supplies rendered for the purpose or with the intent of inducing conception; premarital examinations; impotence, organic or otherwise; tubal ligation; vasectomy; sexual reassignment surgery; reversal of sterilization procedures;
20. Routine newborn infant care, well-baby nursery and related physician charges in excess of 48 hours for vaginal delivery or 96 hours for cesarean delivery. If forty-eight hours following a vaginal delivery falls after 8 p.m., coverage shall continue until 8 a.m. the following morning. If ninety-six hours following the cesarean section falls after 8 p.m., coverage shall continue until 8 a.m. the following morning;
21. Services mainly rendered for custodial, occupational therapy, or in-vivo therapy; (except for rehabilitation facility treatment charges incurred for the treatment of mental or nervous conditions);
22. Services provided normally without charge by the health service of the policyholder; or services covered or provided by the student health fee; service received by dependents/spouses at the WHC;
23. Supplies, except as specifically provided in the policy;
24. Surgical breast reduction, breast augmentation, breast implants or breast prosthetic devices, or gynecomastia; except as specifically provided in the policy;
25. The administration of oral chemotherapy drugs (the administration is excluded not the drugs);
26. Treatment in a government hospital, unless there is a legal obligation for the insured person to pay for such treatment;
27. War or any act of war, declared or undeclared; or while in the armed forces of any country (a pro-rata premium will be refunded upon request for such period not covered); and
28. Weight management services and supplies related to weight reduction programs, weight management programs, related nutritional supplies, treatment for obesity (treatment of morbid obesity is covered). Morbid obesity is defined as follows: Morbid obesity is associated with serious and life threatening disorders such as diabetes mellitus and hypertension. Morbid obesity means a body weight of two times the normal weight or greater, or 100 pounds in excess of normal body weight based on normal body weight using generally accepted height and weight tables for a person of the same age, sex, height, and frame. Benefits will be provided only upon written request for treatment with a treatment plan written by a physician, and services or treatment must meet the company's medical criteria.) and surgery for removal of excess skin or fat. Exception: benefits will be provided for the treatment of dehydration and electrolyte imbalance associated with eating disorders.

All benefits provided outside of Wardenburg Health Center are underwritten by the Chickering Group/Aetna and the benefits payable are as defined in and subject to all provisions of the policy. (www.chickering.com)