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limitations and This is a partial and summarized list of nitations and exclusions. Your group .,lay have specific limitations and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment will be determined. Unless stated otherwise, no coverage will be provided tor the following sinIatiollS. I. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness or injury tor which the insured person is in any wny paid or entitled to payment or care and treatmenr by or through a governmenr program, ocher than Medicaid or as otherwise provided by Tex.1s law. 3. Education or training; medical services provided by che insured person's parent, spouse, brother, sister or child. 4. Investigational or experimental drugs or substances nor approved by Humana or by the Food and Drug Administration. =>. Treatment, sen'ices. supplies or surgery chat is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. TX-23441-HH 1/04 e Exclusions 7. Weekend non emergency hospital awnissions. 8. In-vitro tertilization. unless our In- Viero Fercilization Rider is included in the Group Policy; any medical or surgical treatment of intertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic. cosmetic or reconstructive surgery. unless a functional impaimlenc is presenr or if required to correct a congenital defect. birth abnormalicy of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treannent of teeth or periodontium or otal surgery, unless the e)..-penses a. are medically necessary diagnostic and/or surgical treamlent of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a tumor or lesions in che mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw, ex.cept injuries resulting from biting or che\\'<ing, sustained while the person is covered by the Group Policy. For all injury, the care and treatment must be provided within the '12 monch period beginning on che date of the injury. Also. the insured person must remain covered f l!!2.~~:_. Insured by Humana Insurance Company @2004 Humana Inc. e under che Group Policy during the 12 month period while the care and treannent is being received. We will not cover any trearmenc related co che preparation or the titting of dentures. including dental implants. 11. Any service, supply or treatment connected with .custodial care. 12. Sickness or injury caused by the insured person's: a. engaging in an illegal occupation: or b. commission of or an attempt to commit a criminal act. 13. Any treatment to reduce obesit)" including, but not limited to. surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy would endanger the life of the mocher: or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to the abortion. '15. Vision analysis, testing or orthoptic training or che purchase of eyeglasses' or concact lenses. 16. Care and treatment of complications of noncovered procedures. unless required by state law.