This Plan does not cover nor provide benefits for:
- Services rendered after termination of participation in the Plan.
- Services or supplies which constitute personal comfort or beautification items, television or telephone use, or in connection with custodial care, education, or training, or expenses actually incurred by other persons except as specifically addressed under Covered Medical Expenses.
- Services needed due to war or any act of war, whether declared or undeclared.
- Expense incurred as a result of commission of a felony.
- Expense incurred by a covered person, not a United States citizen, for services performed within the covered person's home country, if the covered person's home country has a socialized medicine program.
- Expense incurred for any services rendered by a member of the covered person's immediate family or a person who lives in the covered person's home.
- Services rendered for treatment of any Sickness or Injury for which benefits are available under workers' compensation employer liability law or services for any occupational Sickness or Injury. Occupational sickness or Injury includes those as a result of any work for wage or profit.
- Charges for completion of claim forms.
- Education classes, including charges for natural childbirth instruction.
- Services performed for cosmetic or reconstructive surgery or complications of cosmetic or reconstructive surgery procedures unless:
- The condition is necessary as the result of an accident of Sickness
- Scar revision due to an accident or Sickness
- Correction of congenital defects which interferes with bodily function
- The services are performed during the period a Participant is participating under the plan, and
- The services are for reconstruction of the breast on which a mastectomy was performed, surgery and reconstruction of the other breast to achieve symmetry in appearance and necessary prosthesis or physical complications at any stage of mastectomy, including lymphedemas. These procedures shall be performed in a manner determined in consultation with the patient and the patient's attending physician.
- Charges which are payable by any third party due to legal liability including, but not limited to, professional liability insurance, motor vehicle liability insurance, individual liability insurance, and any other source from which medical benefits would be paid if this Plan did not exist, whether or not legal action is taken on behalf of the Participant.
- Charges to the extent of coverage required by, or available through, any federal, state, municipal or other governmental body or agency, except as otherwise states in the Plan and except for medical assistance under a state plan for medical assistance covered under Title XIX of the Social Security Act ("Medicaid")
- Experimental/Investigative drugs, chemical, services or procedures, except where covered in the Policy.
- Expense incurred when the person or individual is acting beyond the scope of his/her/its legal authority.
- Music Therapy, vision therapy or remedial reading therapy.
- Expense for personal hygiene and convenience items, such as air conditioners, humidifiers, hot tubs, whirlpools, or physical exercise equipment, even if such items are prescribed by a physician.
- Charges and services related to a newborn who is not a participating Dependent.
- Dental expenses except as specifically addressed under Covered Medical Expenses.
- Reversal of sterilization for Participating Student, Spouse, Domestic Partner or Dependent.
- Services or supplies rendered or furnished in a Military or Veterans Administration Hospital, unless rendered in connection with Disability which is not in any way related to the Participants military service.
- With respect to diagnostic testing:
- Tests performed more frequently than is necessary according to the diagnosis and accepted medical practice
- Genetic testing unless family history necessitates.
- Premarital examinations.
- Duplicate testing by different Physicians unless Second Opinions are authorized herein,
- Test associated with routine visits except those covered under the Wellness benefit provision.
- With respect to consultations:
- Telephone only consultations.
- Consultations for indelible or unnecessary procedures.
- Services rendered by practitioners other than Physicians.
- With respect to Infertility:
- Invitro or invivio fertilization, artificial insemination, or any other impregnation procedure.
- Fertility drugs.
- Any treatment other than that which treats a medical condition.
- Diagnostic tests unless necessary to diagnose a medical condition.
- Fertility supplies, treatment and counseling.
- With respect to Hospital services:
- Room and Board Charges made by a facility other than a Hospital or Extended Care Facility.
- Admission for observation, rest, physical therapy, or testing.
- Weekend admissions except for Medical Emergencies.
- Charges for any period of confinement prior to the day before scheduled Surgery unless a documented hazardous medical condition exists.
- Charges deemed not Medically Necessary by the Utilization Review Service and/or Claims Administrator.
- Expense for transplant expenses, unless otherwise provided on the Policy.
- Expense incurred for eye refractions, vision therapy, radial keratotomy, eyeglasses, contact lenses (except when required after cataract surgery), or other vision or hearing aids, or prescriptions or examinations except as required for repair caused by a covered injury, unless otherwise provided in this Policy.
- Penile implants and/or any related expenses unless having organic origin.
- Expense for services or supplies provided for the treatment of obesity and/or weight control, unless specifically provided for in the policy.
- Expense incurred for alternative, holistic medicine, and/or therapy, including but not limited to, yoga and hypnotherapy.
- Expense incurred for acupuncture, unless services are rendered for anesthetic purposes.
- Medical care claims filed more than fifteen (15) months from the date of service.
- Care and treatment that is deemed not Medically Necessary.
- For removal of excess skin unless Medically Necessary.
- Expense 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.
- Expense incurred for elective treatment or elective surgery except as specifically provided elsewhere in this Policy and performed while this Policy is in effect.
- Expense for treatment of covered students who specialize in the mental health care field, and who receive treatment as a part of their training in that field.
- For all NCAA Sanctioned Intercollegiate Sports Injuries, the Plan is primary for the first $90,000 of eligible expense per injury and secondary to coverage provided under the NCAA catastrophic policy.
If coverage provided by this policy violates or will violate any economic or trade sanctions, the coverage is immediately considered invalid. For example, Aetna companies cannot make payments for health care or other claims or services if it violates a financial sanction regulation. This includes sanctions related to a blocked person or a country under sanction by the United States, unless permitted under a written Office of Foreign Asset Control (OFAC) license. For more information, visit http://www.treasury.gov/resource-center/sanctions/Pages/default.aspx.
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator
P.O. Box 14462
Lexington, KY 40512
800.648.7817, TTY: 711
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 800.368.1019, 800.537.7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).