Bakery Drivers Local 734 - Health and Welfare Fund | What Is Not Covered
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What Is Not Covered

What The Plan Does Not Cover

PLAN CONDITIONS, LIMITATIONS AND EXCLUSIONS

No payment will be made under any applicable benefit provided under the Plan for loss sustained as a result of, or for charges incurred for, any of the services, supplies, charges or types of treatment listed below.

NO BENEFITS ARE PAYABLE FOR THE FOLLOWING:

  1. Charges incurred by a person who is not covered under the Plan at the time the charges are incurred.
  2. Charges incurred by a covered person for a particular type of treatment once the person has received Plan benefits totaling any applicable maximum benefit for that type of treatment during any stated period of time.
  3. Treatment of a preexisting condition of a covered person after $500 in benefits have been paid for any such condition during the first 12 months after the person’s enrollment date.
  4. Charges incurred for medical, dental, vision or hearing treatment provided to a covered person outside the United States of America, its Territories, and Canada after $250 in benefits have been paid for such treatment except in the case of emergency treatment provided as a result of a life-threatening condition.
  5. Any room and board charges incurred for any days of inpatient hospital care that are not precertified as medically necessary under the Medical Care Review Program.
  6. Services or supplies related to the following that were not been precertified (determined to be medically necessary and within the Plan’s coverage guidelines) by Med-Care:
    • Chiropractic care
    • Infertility
    • Hospice care
    • Surgical facility fees for podiatric (foot) sugery
    • TMJ
    • Obesity
    • Medical equipment
  7. Services and supplies which are not recommended or approved by the attending doctor.
  8. Under the Comprehensive Benefit (medical plan), any amount in excess of the allowable charge; or with respect to the other benefits provided the Plan, any charge that is in excess of a reasonable and customary charge.
  9. Charges incurred for routine care (except as specifically stated otherwise on this site or in the plan booklet).
  10. Services or supplies that are not medically necessary unless specifically set forth as a covered expense or covered medical expense.
  11. Services or supplies received from any hospital or doctor who does not meet this Plan’s definition of “hospital” or “doctor.” (Also see exclusion No. 22.)
  12. Services, supplies, treatments, or procedures that are not provided for the treatment or correction of, or in connection with, a specific non-occupational accidental bodily injury or sickness unless specifically identified as being covered under the Plan.
  13. Services provided to a covered person by an individual who ordinarily lives in your home or in the home of the covered person receiving the services, or who is your or your spouse’s close relative. A “close relative” means your spouse, or your or your spouse’s child, son-inlaw, daughter-in-law, brother, brother-in-law, sister, sister-in-law, parent, father-in-law or mother-in-law.
  14. Eye refractions, eyeglasses or contact lenses, including any charges made for follow-up treatment or for the fitting of any of these appliances, except as may be provided after cataract surgery or under the Vision Benefit.
  15. Services, supplies, or procedures that are experimental or investigative in nature, or any services, supplies, or procedures that are provided in connection with any treatment or procedure that is experimental or investigative.
  16. Services, supplies or treatments which are preventive in nature, except as specified under the Wellness Benefit.
  17. Services, treatments, programs or surgical procedures provided in connection with an overweight condition or condition of obesity or morbid obesity, but only if all the following requirements are met:
    • The person is 100 pounds over his medically desirable weight.
    • The person has a Body Mass Index (BMI) of 45 or more.
    • The obesity is a threat to the person’s life due to other complicating health factors, such as diabetes, heart trouble, hypertension, etc.
    • The person has a history of unsuccessful attempts to reduce weight by more conservative measures.
    • Med-Care has precertified the treatment.
  18. Travel, whether or not recommended by a doctor, except as specifically provided in No. 15 in “Medical Benefits” section.
  19. Any elective or non-emergency plastic or cosmetic surgery on the body except as specifically provided under No. 11. in “Medical Benefits” section.
  20. Reversal or attempted reversal of vasectomies or other sterilization procedures.
  21. Vasectomies or other sterilization procedures for dependent children.
  22. Services provided by a surgical assistant who is not an medical doctor (M.D. or D.O.). This exclusion applies to services provided by Certified Surgical Assistants (C.S.A.’s) and other practitioners of similar training and degree.
  23. Services of naprapaths. (Naprapaths use massage and diet therapies, and are not licensed as “physicians” in the state of Illinois).
  24. Surgical or laser procedures performed to correct nearsightedness, farsightedness or astigmatism, including a radial keratotomy (RK) or LASIK procedure.
  25. Contraceptive devices, except for oral birth control medications.
  26. Services and supplies provided as a result of dental surgery, dental x-rays, or any other dental treatment, except as specifically provided under No. 14 in “Medical Benefits” section, or as covered under the Dental Benefit.
  27. Treatment, therapy or counseling for infertility, or artificial insemination or any related procedures, whether experimental or not, including but not limited to in vitro or in vivo fertilization, egg implantation, etc., or hormone therapy or any other direct attempt to induce or facilitate conception. (However, the Plan will cover the initial diagnostic testing to determine the cause of the infertility. Med-Care must precertify the tests as medically necessary and covered under the terms of the Plan.)
  28. Vitamins, nutritional supplements, food supplements or any other items of a like nature, whether or not prescribed by a physician.
  29. With respect to the Prescription Drug Program:
    • Viagra and similar oral prescription drugs for male impotence except as specified under the Mail Service Program.
    • Proton-pump inhibitors (PPIs) such as Nexium, Prevacid and Prilosec, unless precertified by Med-Care; and
    • Non-sedating antihistamines (NSAHs) such as presciption Claritin and Allegra, unless precertified by Med-Care.
  30. Special education, regardless of the type or purpose of the education, the recommendation of the attending doctor or the qualifications of the individual providing the education.
  31. Education, training, or room and board while the person is confined in an institution which is primarily a school or other institution for training, a place of rest, or a place for the aged.
  32. Marriage counseling or services provided by a social worker.
  33. Physical therapy, speech therapy, or any other type of therapy if either the prognosis or history of the person receiving the treatment or therapy does not indicate that there is a reasonable chance of improvement.

    Exception: This exclusion does not apply to therapy that may be provided as part of an authorized program of hospice care.

  34. Confinement, care, treatment, services or supplies provided in a nursing home, rest home, convalescent home or similar establishment.

    Exception: This exclusion does not apply to short-term skilled nursing facility care that may be provided as part of an authorized program of hospice care.

  35. Orthopedic shoes (except for children under one year of age).
  36. Custodial care except as may be provided as part of an authorized program of home health care or hospice care.
  37. Any of the following items or items of a similar nature or purpose, regardless of intended use:
    • air conditioners
    • air purifiers
    • blankets or mattress covers
    • blood pressure instruments
    • breast pumps
    • chiropractic braces
    • commodes
    • communication devices (except following a laryngectomy)
    • dehumidifiers
    • devices or surgical implantations for simulating natural body contours (except for breast prostheses following mastectomy)
    • elevators or stair lifts
    • exercising equipment
    • health club memberships
    • humidifiers
    • heating units
    • orthopedic mattresses
    • pillows (including allergy-free pillows)
    • scales
    • stethoscopes
    • swimming pools
    • thermometers
    • stockings (except as stated in No. 27-j in “Medical Benefits” section)
    • vibratory equipment
    • wigs (except as stated in No. 27-k in “Medical Benefits” section)
    • whirlpools
  38. Transplant donor searches including testing of potential donors.
  39. Genetic testing unless the result of the test will directly impact the treatment being delivered to a patient who has a diagnosed medical condition.
  40. Surrogacy or surrogate fees. This exclusion applies to, but is not limited to, charges in connection with; a) the medical or other expenses of a surrogate who carries and delivers a child on behalf of a person covered under this Plan; or b) a female employee’s or dependent’s carrying and delivering a child for someone else. Any child born of a covered person acting as a surrogate mother will not be considered a dependent of the surrogate mother or her spouse.
  41. Special home construction to accommodate a disabled person. Exception: The Plan will cover the cost of a chair lift that meets the requirements described in No. 27-l in “Medical Benefits” section.
  42. Repair or maintenance of prostheses, appliances, wheelchairs or other medical equipment (even if the Plan covered the purchase of the equipment).
  43. Treatment of accidental bodily injury, sickness, or disease sustained while the person was performing any act of employment or doing anything pertaining to any occupation or employment for remuneration or profit for which benefits are payable in whole or in part under any Workers’ Compensation Law, Employer’s Liability Law, Occupational Diseases Law or similar law. This exclusion applies to services designed to enable a person to perform an occupation, including but not related to work hardening or any other occupational training, exercise or therapy regimen.
  44. Any inpatient or outpatient treatment program for chemical dependency, including follow-up care, if the person does not complete the treatment program in full (unless the early discharge is due to medical reasons beyond the patient’s control).
  45. Any hospitalization for any dental procedure for a covered person age 6 or older; or any procedure not performed in a dental office setting.
  46. Treatment, care, services, supplies or procedures furnished by or payable under any plan or law of any government, federal or state, dominion or provincial, or any political subdivision of such.
  47. Treatment, care, services, supplies or procedures provided while a covered person is confined in a hospital owned or operated by a state, province, or political subdivision, or owned or operated by the United States Government or an agency of the United States Government. However, if charges are made by a Veterans Administration (VA) hospital which claims reimbursement for the “reasonable cost” of care furnished by the VA for a non-service-related disability, to the extent required by law such charges will be considered covered medical expenses to the extent that they would have been considered covered medical expenses under the Plan had the VA not been involved.
  48. Treatment, care, services, supplies or procedures which are furnished, paid for or otherwise provided due to past or present service of any individual in the armed forces of a government or for services provided or made available by any military facilities.

    Exception: If a covered person is a reservist who is called up to active military duty for more than 30 days and continues Plan coverage through COBRA coverage, or if the covered person is a dependent of such a reservist, this exclusion will not apply to the extent that the Plan is required by law to provide coverage for non-service-related conditions.

  49. Services, supplies, treatment or hospital confinements for which the person is not legally required to pay.
  50. Charges made that would not have been made if this Plan did not exist.
  51. Treatment of injury or sickness caused by: war, or any act of war, whether or not war is declared; any act of international armed conflict; any conflict involving the armed forces of an international body; or insurrection.
  52. The completing of claim forms (or any forms required by the Plan for the processing of claims) by a doctor or other provider of medical services or supplies, or charges made for providing medical records.

This list is not an all-inclusive list of the Plan’s limitations and excluded services, supplies, and treatments. It is only representative of the types of services, supplies, and treatments, or the types of situations in which charges may be incurred, for which no payment is made. Basically, benefits are payable under this Plan only for the direct treatment of nonoccupational accidental injuries and sicknesses.