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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 tlIis list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment ~;ll be determined. Unless srated otherwise, no coverage will be provided for the foUowing situations. I. A sickness or injury which is covered undel' <lnyWorkers. Compensation or similar law. Sickness or injury for ,"vhich the insured person is in any way paid or entitled to payment or care and treatment by or through a government program, other than Medicaid or as otherwise provided byTex.1S law. Education or training; medical services provided by the insured person's parent, spouse, brother, sister or child. Investigational or experimental drugs or substances not approved by Humana or by the Food and Drug Administration, Treatment, services. supplies or surgery that is not medically necessary. Purchase or fitting of hearing aids, implantable hearing devices or advice 011 their care, unless provided by rider. 2. 3. 4. :>. 6. l. (~ TX-23441-HH 1/04 e Exclusions 7. 'Weekend nonemergency hospital admissions, 8. In-vin-o fertilization. unless our In-Vitro Fertilization Rider is included in the Gmup Policy; any medical or surgical treatment of infertility; infertility evaluations; sex change services or reversal of elective sterilization. 9. Plastic. cosmetic or reconstructive surgery. unless a functional inlpairment is present or if required to correct a congenital defect, birth abnormality of a newborn or for breast reconstruction or as otherwise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the e)..-penses a. are medically necessary diagnostic and/or surgical n'eannent of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical removal of a n1ll1Or or lesions in the mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw, exce.pt injuries resulting from biting or chC"l.\>ing, sustained while the person is covered by the Group PoliC}~ For an injury, the care and treatment must be pl-o\'ided within the 12 month period beginning on the date of the injury. Also, the insured person must remain covered }~Ff..TL~~:m_ Insured by Humana Insurance Company @2004 Humana Inc. e under the Group Policy during the 12 month period while the care and treatment is being received. We ,""ill not cover any treannent related to the preparation or the fitting of dentures. including dental implants. II. Any service, supply or treaonent 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 n'eatment to reduce obesity, 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 mother; 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 the purchase of eyeglasses or contact lenses. 16. Care and treannent of complications of noncovered procedures. unless required by state law.