06-30-04 Chapter 172 Employee Retiree Insurance and Benefits Board Meeting minutes

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limitations and ['his 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 othenvise. no coverage 'will be provided for the following situations. 1 . A sickness or injury 'which is covered under any Workers' Compensation or similar law. 2. Sickness or injury for which the insured person is in any ,"vay paid or entitled to payment or care :t9-d treatment by or through a government program, other than Medicaid or as otheT'\.v;se provided by Texas law. 3. Education or training; medical services provided by the insured person's parent, spouse, brother, sister or child.. 4. Investigational or e"..perimental drugs or substances not approved by Humana or by the Food and Drug Administration. 5. Treattnent, services, supplies or surgery tllat is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advlce on their care, unless provided by rider. TX-10434-HH 1/04 Exclusions 7. Weekend nonemergency hospital admissions. 8. In-vitro fertilization. unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical trearmenr of infertility; infertility evaluations; sex change seT'\.>1ces or reversal of elective sterilization. 9. Plastic, cosmetic or reconstructive surgery, unless a functional impairment is present or if required to correct a congenital defect, birth abnormality of a newborn or for breast reconstrUction or as otheT'\.vise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the e~l'enses a. are medically necessary diagnostic and! or surgical treattnent of the temporomandibular Gaw or craniomandibular) joint; b. are for the surgical remov:u of a tumor or lesions in the mouth; or c. are incurred in connection with an injury to sound natural teeth or jaw, except injuries resulting from biting or ch~...ing, sustained while the person is covered by the Group Policy. For an injury, the care and treatment must be provided within the 12 month period beginning on the date of the injury. Also. the insured person must remain covered :K l!}!.~~:m_ Insured by Humana Insurance Company @2004 Humana lnc. under the Group Policy dunng the 12 month period while the care and trearment is being received. We Vi.>iIl not cover any treatment related to the preparation or the fitting of dentures. including dental implantS. 11. l'l.IJ.Y sen-"ice, supply or rreamlent 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 obesity, including. but not limited to. surgical procedures. 14. Electi\1e 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 n'eat medical complications due to the abortioll. 15. VJ.Sion analysis. testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and trearment of complications of none overed procedures. unless required by state law.