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<br />limitations and <br />..""his is a partial and summarized list of <br />-nitations and exclusions. Your group <br />_ilay have specific llinitations and <br />exclusions not included on this list. <br />Please check your Certificate for this <br />complete listing. The Certificate is the <br />document upon which benefit payment <br />will be determined.. <br /> <br />Unless stated odlervv-ise, no coverage '\'I,-iJ] be <br />provided for the folJo,,,-ing situations. <br />I . A sickness or injury which is covered <br />under any Workers' Compensation or <br />similar law. <br />2. Sickness or injury for which the insured <br />person is in any ,vay paid or entitled to <br />payment or care and treatment by or <br />through a government program, other <br />than Medicaid or as othen.v-ise provided <br />by Texas law. <br />3. Education or training; medical services <br />provided by the insured person's parent, <br />spouse, brotl1er, sister or child. <br />4. Investigational or e:l..-perimental drugs or <br />substances not approved by H1IDlana or <br />by the Food and Dmg Administration. <br />5. Treatment, services, supplies or surgery <br />that is not medically necessary. <br />6. Purchase or fitting of hearing aids, <br />implantable hearing devices or advice on <br />their care, unless provided by rider. <br /> <br />TX-23441-HH 1/04 <br /> <br />Exclusions <br /> <br />7. Weekend nonemergency <br />hospital admissions. <br />8. In-.-itro fertilization. unless our In-Vitro <br />Fertilization Rider is included in the <br />Group Policy; any medical or surgic3.I <br />treaunem of infertility; infertility <br />evaluations; sex change services or <br />reversal of elective sterilization.. <br />9. Plastic. cosmetic or reconstrUctive <br />surgery, unless a functional inlpairment is <br />present or if required to correct a <br />congenital defect. birth abnonnality of a <br />newborn or for breast reconstrUction or <br />as othen..-ise stated in the certificate. <br />10. Services and supplies for dental care, <br />treatment of teeth or periodontium or <br />oral surgery, unless the expenses <br />a. are medically necessary diagnostic <br />and/ or surgical treatment of the <br />temporomandibular Gaw or <br />craniomandibular) joint; <br />b. are for tl1e surgical removal of <br />a tumor or lesions in the mouth; or <br />c. are incurred in connection v;.-itll an <br />injury to sound natural teem or jaw, <br />except injuries resulting from biting <br />or che,^-wg, sustained while the <br />person is covered by the Group <br />Policy. For an injury, the care and <br />treatment must be provided vi>ithin <br />the 12 monm period beginning on <br />the date of me injury. Also, the <br />insured person must remain covered <br /> <br />JZ l!.TL~~:m_ <br /> <br />Insured by Humana Insurance Company <br />@2004 Humana Inc. <br /> <br />under the Group Policy during the <br />12 month period while the care and <br />treatment is being received.. We will <br />not cover any treatment related to the <br />preparation or the fitting of dentures. <br />including dental implants. <br />11. Any sen>ice, supply or treatment <br />connected widl custodial care. <br />12. Sickness or injury caused by the <br />insured person's: <br />a. engaging in an illegal occupation; or <br />b. commission of or an attempt to <br />commit a criminal act. <br />13. Any treatment to reduce obesity, <br />including, but not limited to, <br />surgical procedures. <br />14. Elective abortion unless: <br />a. the physician certifies in writing that <br />me pregnancy would endanger the <br />life of the mother: or <br />b. the pregnancy is a result of rape or <br />incest; or <br />c. the senrices are received to treat <br />medical complications due to <br />me abortion. <br />15. Vision. analysis, testing or ortboptic <br />training or the purchase of eyeglasses or <br />contact lenses. <br />16. Care and treatment of complications of <br />noncovered procedures. unless required <br />by state law. <br />