LIMITATIONS & EXCLUSIONS

With respect to all of the benefits provided under the Policy, no benefits will be payable as the result of:
a) suicide or any attempt thereat, while sane or insane.
b) any intentionally self-inflicted injury or Sickness;
c) rest care or rehabilitative care and treatment;
d) cosmetic surgery or care or treatment solely for cosmetic purposes, or complications therefrom. This exclusion does not apply to cosmetic surgery resulting from a covered Accident if initial treatment of the Covered Person is begun within 12 months of the date of the Accident;
e) immunization shots and routine examinations such as: health exams; periodic check-ups; pre-marital exams; and routine physicals (except as described in the schedule of benefits);
f) routine newborn care, including routine nursery charges;
g) voluntary abortion, except with respect to the Insured or covered Dependent spouse:

1) where such person’s life would be endangered if the fetus were carried to term; or
2) where medical complications have arisen from an abortion;

h) pregnancy of a Dependent child, unless required by law;
i) the treatment of:

1) mental illness;
2) functional or organic nervous disorder, regardless of cause;
3) alcohol abuse;
4) drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed, for more than 10 days in any Calendar/Benefit Year, with respect to payment of the Daily In-Hospital Indemnity Benefit;

j) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority;
k) committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation;
l) participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee-jumping, or hang gliding;

m) air travel, except:

1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or
2) as a passenger for transportation only and not as a pilot or crew member;

n) any Accident occurring as a result of the Covered Person being intoxicated (where the blood alcohol content meets the legal presumption of intoxication under the law of the state where the Accident took place);
o) sex changes;
p) experimental treatments or surgery;
q) the reversal of tubal ligation and vasectomies;
r) artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or Physician’s services, unless required by law;
s) treatment of exogenous obesity or weight control;
t) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization. This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war.
u) accident or sickness arising out of and in the course of any occupation for compensation, wage or profit. Expenses payable under Occupational Disease Law or similar law, whether or not application for such benefits have been made;
v) Pre-Existing Conditions, except as described in the schedule of benefits;
w) air or ground ambulance service (except as described in the schedule of benefits);
x) for loss incurred, care or treatment received, or hospital confinement occurring outside of the United States or its possessions except in the event of an emergency; or
y) Dentistry or oral surgery except:

1) Excision of impacted third molars; or
2) Closed or open reduction of fractures or dislocation of the jaw.

 

In addition to the Exclusions and Limitations for all coverages, the following are not covered under the Outpatient Physician Office Visit and the Outpatient Diagnostic X-Ray and Laboratory Indemnity Benefits:
a) visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while Confined to a Hospital;
b) routine eye examinations or fitting of glasses;
c) fitting of hearing aids;
d) dental examinations or dental care other than expenses resulting from accidental injury; and
e) benefits which are provided under any other part of the Policy.
 
In addition to the Exclusions and Limitations for all coverages, the following are not covered under the Outpatient Prescription Drug Indemnity Benefit, if applicable;
a) drugs and medicines which may be lawfully obtained without a Physician's prescription; except insulin;
b) therapeutic devices or appliances. Including hypodermic needles, syringes, support garments and non-medical items;
c) drugs labeled "Caution - limited by federal law to investigational use" or experimental drugs;
d) drugs, medicines or insulin, in whole or in part, used by or administered to a Covered Person while Confined in a Hospital, rest home, sanatorium, extended care facility, convalescent hospital, nursing     home or similar institution;
e) immunization agents, biological sera, blood or blood plasma; or
f) contraceptive materials, devices or medications or infertility medication, except where required by law.
 

Exclusions may vary by state, refer to the Master Policy for complete list of exclusions.

 

 


 

AmWINS Group Benefits, Inc. (AmWINS) is a Third-Party administrator (TPA) for Companion Life Insurance Company and is an industry leader in distribution, administration and program management across the group benefits sector.  As a leading Third-party administrator, AmWINS is focused on the needs of clients as it relates to group benefits products and services.  AmWINS is a licensed TPA as required by State Insurance Departments.

COVERAGE IS UNDERWRITTEN BY COMPANION LIFE INSURANCE COMPANY under policy form LBHP 3050. 

Companion Life Insurance Company is the insurance company underwriting the limited benefit health insurance included in the program.  The company is located in Columbia, SC, and has been rated A+ (Superior), an independent opinion from the leading provider of insurer ratings of a company’s financial strength and ability to meet its obligations to policyholders, based on an analysis of the financial position and operating performance as of December 18, 2018, by AM Best Company, an independent analyst in the insurance industry.  For the latest rating, access www.ambest.com

 

POLICY BENEFITS, FEATURES AND RATES MAY VARY BY STATE.  Plan offerings are subject to state limitation.  Not all benefits are available in all states.  Please consult your Sales Representative with questions regarding plan offerings.

This document represents a summary of products and services offered under the above-mentioned insurance policy.  Particulars of this plan may differ depending upon group size, plan category and other underwriting considerations which are subject to state insurance laws and the benefits and provisions as described may vary due to said states.  All products described, herein are subject to the terms, conditions, exceptions and limitations of the specific policy.  Please see the specific policy and certificate for details.  Policies may not be available in all states.

Avance Health: A Healthcare Management Platform is described in this document. This is not intended to replace any existing healthcare coverage.  This program is a complementary offering to the existing benefits package and is not a replacement or substitution for any existing health insurance offering.

The Limited Benefit Health Insurance Policy underwritten by Companion Life Insurance Company is a supplemental health plan and does not meet the minimum essential coverage as required by the Affordable Care Act. 

AVANCE HEALTH
A HEALTHCARE MANAGEMENT PLATFORM
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