What the Plan Does Not Cover

(Plan Conditions, Limitations and Exclusions)

No payment will be made under this Benefit Plan for loss sustained as a result of, or for charges incurred for or as a result of, any of the following:

  1. Accidental bodily injury, sickness or disease sustained while the individual was performing any act of employment or doing anything pertaining to any occupation or employment for remuneration or profit.
  2. Accidental bodily injury, sickness or disease for which benefits are or may be payable in whole or in part under any Workers' Compensation Act or any Occupational Diseases Act or any similar law.
  3. Treatment, care, services, supplies or procedures provided while a person is confined in a hospital operated by the U.S. Government or its agency, provided, however, that if charges are made by a Veterans Administration (V.A.) hospital which claims reimbursement for the "reasonable cost" of care furnished by the V.A. 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 had the V.A. not been involved.
  4. Charges incurred by an eligible family member which you or the family member are not legally required to pay.
  5. Education, training or room and board while a person is confined in an institution which is primarily a school or institution of learning or training.
  6. Services or supplies provided while a person is confined in an institution which is primarily a place of rest, a place for the aged, or a nursing home (unless provided during an approved confinement in a facility that meets the definition of a skilled nursing facility—see page 81).
  7. Any type of custodial care, which is care designed primarily to assist an individual in meeting the activities of daily living. This exclusion applies to all such care regardless of what the care is called (unless the care is provided to a person under an approved Hospice Care Program).
  8. Any type of physical examination (employment, pre-marital, school, etc.) or any other medical examination or test for check-up purposes where not necessary for diagnosis or treatment of a sickness, disease or injury. This exclusion applies to hospital care of a well newborn and to well-child checkups, office visits, routine examinations and tests.

    Exceptions - This exclusion does not apply to:

    • Examinations and tests received by employees, retirees and spouses which are covered under the provisions of the Routine Physical Exam Benefit, the Diagnostic X-Ray and Lab (DXL) Benefit, or, with respect to x-rays and lab tests, the Comprehensive Benefit.
    • Routine well-child care provided to a child from birth through age 4 years whose mother (covered female employee or spouse) completed the requirements of the Prenatal Care Program, provided the child is eligible at the time the well-child care is received.
    • Routine childhood immunizations.
    • Colorectal cancer screenings provided in accordance with Provisions Governing Colorectal Cancer Screenings starting on page 50.
  9. Services or treatments which are preventive in nature. This exclusion applies to items such as vitamins or nutritional supplements, and flu shots and other inoculations and treatments which a person may receive as a result of being exposed to a particular disease or to prevent the contraction of any disease, except as provided under the Routine Physical Exam Benefit, the Prenatal Care Program or the Plan's provisions governing coverage for colorectal cancer screenings. Exception - This exclusion does not apply to routine childhood immunizations, or circumcision of a newborn male child during the first 30 days after birth (routine circumcisions performed after 30 days of age are not covered).
  10. Care, treatment, or surgery that is elective, including non-emergency plastic or cosmetic surgery on the body (including but not limited to such areas as the eyelids, nose, face, breasts or abdominal tissue).

    Exceptions - This exclusion does not apply to:

    • Cosmetic surgery for the correction of defects incurred through traumatic injuries sustained as a result of an accident;
    • The correction of congenital defects;
    • Corrective surgical procedures on organs of the body which perform or function improperly;
    • Breast reconstruction following a mastectomy, including surgery on the non-affected breast to achieve a symmetrical appearance;
    • Abortions performed on female employees and retirees and dependent spouses of employees and retirees; and
    • Vasectomies and other sterilization procedures for employees, retirees, and dependent spouses.
  11. Services, treatment, or surgical procedures rendered in connection with any overweight condition or condition of obesity except as stated in Covered Medical Expenses No. 21, page 49.
  12. Treatments, care, services or supplies which are not recommended, ordered or approved by the attending doctor.
  13. Services or supplies received from a doctor or hospital that does not meet this Plan's definition of a doctor or a hospital.
  14. Any service, supply, treatment or procedure which is not rendered for the treatment or correction of, or in connection with, a specific sickness, illness or accidental bodily injury.
  15. Reversal of, or attempts to reverse, a previous elective sterilization.
  16. A pregnancy or pregnancy-related condition of any person other than a female employee or retiree or the spouse of a male employee or retiree.
  17. As a result of treatment or consultation with a social worker or marriage counselor. Exceptions - This exclusion does not apply to services provided under the Hospice Care Program or the Lineco Member Assistance Program.
  18. Care or treatment rendered to you or a dependent which is provided by a person who is a relative in any way to you or to the dependent receiving the care or who ordinarily lives in your home or in the home of the dependent receiving the care.
  19. Physical therapy or any other type of therapy if either the prognosis or history of the person receiving the treatment or therapy does not indicate to the Trustees that there is a reasonable chance of improvement.
  20. Any type of speech therapy except as stated in Covered Medical Expenses No. 6, page 46.
  21. 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.
  22. Eye refractions, eyeglasses (except for up to $200 for the first pair of glasses following cataract surgery), contact lenses (except for the first pair of contact lenses following cataract surgery), dental prosthetic appliances, including any charges made for the fitting or repair of any of these appliances, unless the service or supply is specified as payable under the Dental Benefit or the Vision Care Benefit. (Note - If eyeglasses, contacts or dental prosthetic appliances are damaged or broken as the result of an injury, the Plan does NOT cover any charges for their replacement.)
  23. 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.
  24. Nursery charges beyond the joint confinement of the mother and child or after the end of the period that either the mother or newborn child is no longer medically required to remain in the hospital. In determining a mother's maximum period of medically required confinement, the period of a normal maternity confinement is used. In the event of termination of nursery charges for a newborn child, benefits are payable for the child only if all other eligibility rules of the Fund have been met for that child.
  25. Acute drug or alcohol use.
  26. Hormone therapy, artificial insemination, or any other direct attempt to induce or facilitate fertility or conception.
  27. Any operation or treatment in connection with sex transformations or any type of sexual dysfunction, including any complications arising from such conditions. This exclusion also applies to erectile dysfunction drugs (except for up to 10 tablets a month for the 12-month period immediately following a radical nerve-sparing prostatectomy.
  28. Bodily injury, disease or sickness caused by any act of war, whether war is declared or undeclared, any act of international armed conflict or any conflict involving the armed forces of any international body, or insurrection.
  29. Dental services and supplies rendered for treatment of the teeth, the gums (other than for tumors) or other associated structures primarily in connection with the treatment or replacement of teeth, including treatment rendered in connection with mouth conditions due to periodontal or periapical disease, or involving any of the teeth, their surrounding tissue or structure, the alveolar process or the gingival tissue, unless the charges are for services rendered for the repair of accidental injury to sound natural teeth or are specified as payable under the Dental Benefit.
  30. Travel or transportation, whether or not recommended by a doctor, except as stated in Covered Medical Expenses, No. 8, page 46.
  31. Any treatment, care, services, supplies, procedures or facilities that are experimental or investigative (as defined on page 79).
  32. Any care or treatment of a person once the person has already received Plan benefits totaling the maximum benefit for that type of care and treatment as specified on the Schedule of Benefits.
  33. Treatments, care, services or supplies that are not medically necessary (as defined on page 80) or that do not meet the prevailing standards of medical practice.
  34. Treatment of substance abuse or mental or nervous disorders except as provided under the Mental Health and Substance Abuse Benefit (starting on page 58).
  35. Elective or non-emergency surgery on the jaw, including but not limited to surgery on the maxilla, mandible, and the temporomandibular jaw joint, except as provided in Covered Medical Expenses, No. 18 on page 48.
  36. Individual or private nursing care except as provided in Covered Medical Expenses, No. 15 on page 47.
  37. Any charge or portion of a charge that is determined to be in excess of the amount considered to be reasonable and customary (as defined on page 81).
  38. Accidental bodily injury or sickness for which you or an eligible dependent, whether or not a minor, have a right to recover payment from a third party, except to the extent provided in Payment of Benefits for Compensated Injuries (starting on page 84).
  39. Rental or purchase of any durable medical equipment or other equipment that is not used solely for therapeutic treatment of a single individual's injury or sickness.
  40. Any of the following list of items, regardless of intended use, including but not limited to: air conditioners, air purifiers, whirlpools, swimming pools, humidifiers, dehumidifiers, allergy-free pillows, blankets or mattress covers, commodes, electric heating units, orthopedic mattresses, exercising equipment, vibratory equipment, elevators or stair lifts, blood pressure instruments, stethoscopes, clinical thermometers, scales, elastic bandages or stockings, orthopedic shoes (except as described in No. 19-j on page 49), wigs, devices or surgical implantations for simulating natural body contours, communication devices, breast pumps, or health club memberships.
  41. Chiropractic care in the balance of a calendar year in which an individual has already received payments in the amount of $600 for chiropractic care charges incurred in that calendar year.
  42. In-hospital items such as telephones, TV's, cosmetics, newspapers, magazines, laundry, guest trays, or beds or cots for guests or other family members, or any other personal comfort items or items that are not medically necessary.
  43. Hospital charges for a private room which are in excess of the hospital's most common charge for a semi-private room.
  44. Hospice care except as provided in Provisions Governing Hospice Care (starting on page 52).
  45. Confinement in a nursing facility except as provided in Covered Medical Expenses, No. 16 on page 48.
  46. Non-surgical treatment of TMJ except as provided in Covered Medical Expenses, No. 17 on page 48.
  47. Over-the-counter drugs or medications, or medications that can be legally dispensed by a registered pharmacist without the written prescription of a doctor (except for certain non-prescription diabetic supplies), or more than a 90-day supply of a drug or medicine obtained at one time.
  48. Birth control medications unless they are prescribed by a doctor for therapeutic treatment of a specific sickness, or contraceptive devices or any other method of contraception other than covered surgical sterilization.
  49. Nutritional supplements, food supplements, vitamins or any other items of a like nature, whether or not prescribed by a physician, except as may be expressly stated as covered in Covered Medical Expenses, No. 19-i on page 49.
  50. Any type of service or supply provided in connection with smoking cessation, including but not limited to medications (prescription or non-prescription) and therapy or counseling of any type.
  51. Surgical or laser procedures to correct nearsightedness, farsightedness or astigmatism, including Laser Assisted In-Situ Keratomileusis (LASIK) surgery.
  52. Services or supplies furnished, paid for or otherwise provided due to past or present service of any person in the armed forces of a government.
  53. Services or supplies provided to a person who is not covered under the Plan except as may be provided under the Extension of Benefits provisions of the Plan.
  54. Charges which would not have been made if this Plan did not exist.
  55. Any military service-connected injury or sickness.
  56. Maternity and delivery charges incurred by a covered person acting as a surrogate mother, meaning a female who has become pregnant with a child that is not her own with the intent or understanding that she is to relinquish the child following its birth. In addition, 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.
  57. Genetic testing, including tests for screening purposes or to confirm a diagnosis, except when performed in connection with an actual treatment plan for a diagnosed illness.
  58. Prescription drugs for a Medicare-eligible individual who has elected a Medicare Part D prescription drug plan.

The above is not an all-inclusive listing of excluded services and supplies. It is only representative of the types of services and supplies for which no Plan payment is made and of the types of situations in which loss may be sustained or in which expenses may be incurred for which no payment is made.